San Juan College KIDS KOLLEGE WAIVER 2016
Acknowledgement of Program Information, Authorization for Medical Treatment, and Release of Liability
I, as the parent or legal guardian of the child listed below,
acknowledge that I have been made aware of the following
information about the Kids Kollege program sponsored by San
Juan College:
1. Participation in the Kids Kollege program may be
physically or emotionally demanding. By signing this
Acknowledgement, I hereby state and affirm that my child is in
good health and that he/she is not under a physician’s care for any
undisclosed medical or psychological condition that bears upon
my child’s fitness to participate in Kids Kollege activities. I have
documented all known allergies and medical conditions on the
Kids Kollege Allergies and Medical Conditions form. I acknowledge
that out of consideration for students with severe peanut
allergies, Kids Kollege asks that parents do not send snacks with
peanuts or peanut products.
2. It is the responsibility of the parent or legal guardian
to timely drop off and collect his/her child. The child should be
delivered to his/her classroom no more than 10 minutes before
the start of the class and collected no later than 10 minutes after
the end of class. The Kids Kollege program staff provides runners
from 2:50 p.m. to 3:10 p.m., between afternoon classes, for all
children, ages 6-11, enrolled in back-to-back afternoon classes.
Children ages 4-5 remain in one building (the College’s Child &
Family Development Center) with constant supervision. A child
attending classes off campus will not be provided runners. Every
child age 4-15 must be signed in and out of classrooms upon
arriving and leaving the program. A written letter must be on file
if a parent chooses to allow his/her child, ages 9-15, to leave class
without supervision. Upon receipt of said letter, this child will then
be allowed to sign his or her self in and out. Parents assume
responsibility for their child when signed out of class; there are no
protocols in place for your child’s safety after sign out. If the
parent or legal guardian of the child does not wish for the child to
leave the premises without the parent or without his/her explicit
permission, he/she must make that clear to the child. It is the
responsibility of the parent or legal guardian to ensure that the
child knows who is allowed to collect them. If there is a relevant
restraining order or custody agreement in place, a copy must be
on file; contact the CLC Director at 566-3121 or Assistant Director
at 566-3690. If a parent or legal guardian receives a call from Kids
Kollege requesting pick up of the child, the parent or legal
guardian must make arrangements to collect the child promptly.
3. The Kids Kollege program closes promptly at 5:15 p.m.
every day. Should a child not be collected by 5:15 p.m., staff will
attempt to locate the parent or guardian. At 6:00 p.m., if the child
has not been collected, this will be treated as an instance of
neglect/abandonment and a report will be made to the State of
New Mexico Children, Youth and Families Department. The
Farmington Police Department will be called to transport an
abandoned child to Childhaven. The parent or legal guardian will
be notified of this action by the Police Department and/or
Childhaven. If a parent or legal guardian encounters an emergency
and cannot pick up the child within the times set forth above,
please call 566-3214 to advise the staff.
White Copy-Kids Kollege Coordinator
Yellow Copy-File
Authorization for Medical Treatment
In the event my child is injured or becomes ill while participating
in the Kids Kollege program, I hereby authorize San Juan College
Kids Kollege program staff to administer first aid, arrange for
emergency medical transportation and treatment and to release
medical information provided on the Kids Kollege Allergies and
Medical Conditions form to emergency and health care providers.
I understand payment of these damages or medical expenses is
my responsibility.
Release of Liability
I, as the parent and/or legal guardian, of the child enrolled in San
Juan College’s Kids Kollege, for myself, all family members, or any
other person claiming on behalf of my child, agree to protect,
defend, indemnify and hold harmless San Juan College and its
officials, agents and employees from any and all liability, damages,
injury, claims, suits, liens and judgments, of whatever nature
arising from my child’s participation in the College’s Kids Kollege.
I hereby attest that I am authorized to sign this Acknowledgement,
Authorization, and Release.
Printed Name – Child
Printed Name – Parent/Legal Guardian
Parent/Legal Guardian
Date
(Signature in presence of San Juan College Kids Kollege employee)
Address – Parent/Legal Guardian – Street
Address – Parent/Legal Guardian – City, State, Zip
Phone – Parent/Legal Guardian
Witness/Date
Signature of San Juan College Kids Kollege employee or notary
Date
1. Publicity Release
I hereby voluntarily and without compensation authorize San Juan
College to use my child’s name and photograph in promotion of
the College through radio, television, news media or any and all
other printed and electronic materials. This includes photographs
taken by external media photographers.
Signature – Parent/Legal Guardian
Pink copy-Parent or Guardian
Form updated March 2016
Date
San Juan College KIDS KOLLEGE WAIVER 2016
Acknowledgement of Program Information, Authorization for Medical Treatment, and Release of
Liability
White Copy-Kids Kollege Coordinator
Yellow Copy-File
Pink copy-Parent or Guardian
Form updated March 2016