release form

“Kids Our Kids” Respite Program For Special Families (K.O.K.)

www.KidsOurKids.INFO





Release Form

Child(ren) names: ______________________________________

______________________________________

______________________________________

______________________________________

We must have a completed release form for EACH family in our care. Please read the following information carefully

and sign below.

 I will provide all food and drink items for my child while attending K.O.K. I understand that the volunteers cannot

provide these items for my child.

 I will provide all diapers, clothing and needed supplies for my child while attending K.O.K. I understand that the

volunteers cannot provide these items for my child.

 I understand that pictures and film may be taken at K.O.K. for the purposes of publicity, pictorial recordings and

identification. I give my permission for my child to be photographed while at K.O.K.

 I understand that the only medications K.O.K. volunteers will administer is medications that I provide. All

medications will be administered by a nurse or volunteer director.

 I authorize K.O.K. to administer medical assistance in case of an emergency. I understand that in case of a

medical emergency, 911 will be called. Upon arrival, EMS will administer emergency assistance and if necessary,

my child will be transported to the nearest medical facility for treatment. I understand that I will be contacted

immediately by K.O.K. volunteers via the phone numbers I provide on this form. I understand that I will be

responsible for payment of all EMS, hospital and physician charges for emergency services for my child.

 I have fully disclosed to K.O.K. all pertinent facts about by child’s special needs in writing and accept full

responsibility for failure to do so.

 I release Melissa Rotary, any volunteer group partnered with the Melissa Rotary and any businesses associated

with the Melissa Rotary and the K.O.K. program from any liabilities in caring for my child(ren) while participating

in the K.O.K.

 I understand that the K.O.K. event tonight ends at 10 p.m. and we will need to be prompt and in sound condition

to pick up our child(ren).

By signing below, I understand and agree with the above listed items and authorize K.O.K. to care for my child(ren) this

evening.

_________________________________________ ____/____/_______ ___:_______________

Parent signature Date Time

Contact phone numbers for tonight: ( ) - ____ - ___________ ; ( ) - ____ - ___________

Comments:_________________________________________________________________________________________

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Staff review:__________________________________ Date:_________________________