Public Health 4 Kidz Participation Waiver
Welcome to Public Health 4 Kidz
Public Health 4 Kidz is excited that you will be doing health creatively with us. This waiver is a evergreen release. Please complete the information and waiver below.
Date
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Month
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Day
Year
Date
Applicant Information
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Gender
*
Please Select
Male
Female
Name
First Name
Middle Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Name
First Name
Middle Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Parent's Email
*
example@gmail.com
Parent's Mobile Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Upload your ID picture here (By staff)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload your ID picture here (By staff)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload your ID picture here (By staff)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload your ID picture here (By staff)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload your ID picture here (By staff)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload your ID picture here (By staff)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Enrollment Status
Please Select
Old Student
New Student
Student No.
Media Release
Media Release Form
Media Release Form Purpose: Grant permission to use student photos/videos for promotion.
*
Consent for Media Release.
I give permission to use my child’s photo/video.
I do NOT give permission.
SCIENCE LAB PARTICIPATION WAIVER AND RELEASE OF LIABILITY
Acknowledgment and Assumption of Risk, I ___________________the undersigned parent/legal guardian of the above-named child, understand that participation in science lab activities involves inherent risks, including but not limited to exposure to non-toxic chemicals, use of lab equipment (e.g., beakers, droppers, microscopes), and other hands-on learning materials. While all safety precautions will be taken, accidents or injuries may occur. I acknowledge and voluntarily assume all risks associated with participation in this program. Medical Authorization. In the event of an emergency, I authorize the program staff to seek necessary medical treatment for my child. I agree to be responsible for any resulting medical costs. Release and Waiver of Liability. I hereby release, discharge, and hold harmless Public Health 4 Kidz Production LLC, its directors, employees, volunteers, and agents from any and all liability, claims, or demands arising from my child’s participation in this program.
Refuse Services
Right to Refuse Participation / Removal from Program / Lab / Activities Public Health 4 Kidz Production reserves the right to refuse participation or to excuse any child/person from the program at any time, without refund, if the child/person’s behavior poses a safety risk, disrupts the learning environment, or otherwise violates program rules or policies.
Parent Signature
Date
-
Month
-
Day
Year
Date
Email
example@example.com
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LAB SAFETY RULES
EBEEA OATH
I __________________________ (Child state your name) will follow the laboratory safety rules to keep myself, friends, and lab assistants safe. Child Signature
Parent Signature (if child is a minor, under 18 years)
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Homeschool Attendance Policy (Skip if not homeschool)
Homeschool Co-op Attendance Policy 1. General Expectations. Families are expected to attend all scheduled co-op days they are registered for students should arrive on time and be ready to participate. Notify a co-op leader if you will be absent or late. 2. Absences Planned Absences: Notify the co-op at least 48 hours in advance. Unplanned Absences (illness, emergency, etc.): Notify the co-op as soon as possible by phone, GroupMe, text, or email. 3. Attendance Requirements. Students may not exceed 3 unexcused absences per semester. If absences exceed this limit, the family may be placed on a probationary status or be asked to withdraw to open space for other families. 4. Illness Policy. For the health and safety of all: Stay home if your child or anyone in your household has a fever, vomiting, diarrhea, or contagious illness within the past 24 hours. Notify the co-op if your child has been diagnosed with a reportable contagious illness (e.g., strep throat, flu, COVID-19, and stomach virus). 5. Participation & Commitment. Consistent attendance ensures smooth class instruction and supports group projects. Families are responsible for staying updated on assignments or missed materials when absent. 6. Repeated Tardiness or Absenteeism. Habitual tardiness or absences may result in: A meeting with co-op leadership Reassignment of volunteer duties Possible removal from the program if issues persist. 7. Weather or Emergency Closures. The co-op will follow local school district closures or send an official notification via text/email in case of emergencies or inclement weather.
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Parental Information
Name of Mother
First Name
Middle Name
Last Name
Mother's Job/Position
Mobile Number
Address of Mother
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Father
First Name
Middle Name
Last Name
Father's Job/Position
Mobile Number
Address of Father (if not the same as above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Full Name of Parent
First Name
Last Name
Parent's Signature
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Contact In case of Emergency
Name
First Name
Middle Name
Last Name
Mobile Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship
Submit
Submit
Should be Empty: