BYU-I ECE/EC$E Program

Waiver Agreement and Release Fomr

I de$ire that my child participate in activities related to the EC$E 425: Strategie$ for Early Chilcthood and Special Educationw courss,
ln consideration of BYU-ldaho accepting my child for participation in this program,

1. I consent to testing, photographing, and videotaping of my child when approved by the college faculty.
2. I understand that video tapes and the copyright lo the content therein are owned by BYU-ldaho and may be
used for generat educatlonal purposes at BYU-ldaho,
3. I acknowledge that there are risks of accidental injury through participation in the program and I assume
those risks for my own child.
4. I will provide my own medical and hospital insurance (or I am self-insured) as to any injuries which my result
to my child.
5. I covenant on behalf of my child, myself and my spou$e, if any that no claim shall be brought against BYU-
ldaho or its employees or agents as to any injury which may involve my child arising from participation ln this program
even if caused by negligence of BYU-ldaho; I release BYU-ldaho and its employees and agents from any such claim
which may arise; and lfurther covenant and agree to indemniff and hold harmless BYU-ldaho and its employees
fmm any claim by any person which may arise as a result of my child's participation in the program.

Name of Child:

Birth date,

Signature;

Date:

lnsurance Coverage

lnsuranceCompany t-,i i tr {-/'.:t', policy#

lnsurance coverage is current and to date, and the concerned child is covered by the policy.
CS No

Emergency Phone Numbers (other than parent)

612n.," ,i'. ii';', ui i;

rvr*u,J1lf i [a ( dcry^ Phone.

Famiry rnr'*,.n, ,@ 3ff{'i}r3 fi1/tU f,a"/ phone-

lmmunization Form
My child's immunizration schedule is cunent and up to date, and a copy has beefi provided.
,i
Yes V
l, the undersigned, authorize the staff of the BYU-Idaho Play/guided learning Lab Program andlor medical personnel to take whatever
emergency medical measures are deemed necessary for the care and protection of my child while he/she is enrolled in the program.
- ' \ '4-
' -''' t- ''i'"'t 'n'
Signature (parent or guardian) 7-":--rf
,,/. Date - .. r

I give my permission for a BYU-ldaho teacher candidate to have access to my child's IFSPIIEP and/or gather information to document
mYchird'seducationarprosress'
Yrr vnn Ie W* ll d Klla_
I 'Child ' Parent Signature Dhte