CONSENT TO RELEASE OF EDUCATION RECORDS AND OTHER CONFIDENTIAL

INFORMATION
(High School)

I, Parent/Guardian of ___________________ hereby request __(See school name below)___ to list

KIPP NYC through College (KTC) as a secondary parent contact throughout the duration of high
school for my Child and authorize the School to release educational records and other confidential
information to KTC.

I authorize the School named below to release the following information to KTC
as requested by KTC staff members:

• Copies of all parent information including report cards, progress reports, teacher
comments, newsletters, etc

• Copies of all financial statements including monthly invoices, registration/general fees,

scholarships, and financial aid

• Any and all confidential information requested by KTC and all other materials, written,
requested or required relating to the student named above.

In addition, I authorize the School named below to allow KTC staff members to meet with my child on
school premises.

I also authorize KTC Staff to speak directly with teachers or administrators at the School named
below and authorize teachers and administrators at the School to discuss my child freely and frankly
with KIPP staff members.

I understand KIPP’s request for my consent is to aid in High School and College Advisement.

I understand that my consent is voluntary and may be revoked at anytime.

I hereby release ___(See school name below)____, its officers and employees, of and from any
liability to me/us arising from or related to the provision of such reports, materials, or information.

Student’s High School Name: _______________________________

_______________________________
Signature of Parent/Guardian

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 KIPP NYC THROUGH COLLEGE CONSENT AND RELEASE FORM 
 
ACTIVITY/TRIP NAME: KIPP NYC through College (KTC) 
     

DESCRIPTION/LOCATION/METHOD OF TRANSPORTATION:  Afterschool and weekend activities run by KTC staff, which 
take place at a KIPP NYC middle school.  Students are responsible for their own transportation. On occasion, KTC may 
provide subway passes for students in need. 
 
DATES: From 7th grade through the student’s 18th Birthday  

I, ________________________, am the parent or legal guardian of the minor child/children listed below. I give my permission for my 
child/children to participate in the activity or trip listed above. I understand that participation in KTC includes physical education as 
well as classroom activities and off‐site trips. (For trips: I have read the information provided, if any, about the trip identified above.)   
 

ACKNOWLEDGEMENT OF RISKS AND ASSUMPTION OF RISK AND RESPONSIBILITY 
(Whenever the word « child » is used in this form, the term refers to all of the children identified at the bottom. I understand that in 
signing this Trip and Activity Consent and Release Form I am consenting to the participation in trips and or activities for all of the 
children named above. If I am a student over the age of 18, I am signing this form on my own behalf.)  
 
ACKNOWLEDGMENT OF RISKS: I recognize the fact that there are risks, foreseeable and unforeseeable, in the activities described 
above and in all trips and all travel related activities. I realize that my child could suffer death or injury or illness and require medical 
attention. I acknowledge these risks and confirm that my child’s participation in this activity or trip is voluntary. I consent to my 
child’s participation in this trip and all activities except for the following_________________________________________________. 
 
EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY: My child’s participation in the above named activity or trip is voluntary and I 
assume all risks and full responsibility, on behalf of all parties including myself, my child, my child’s other guardians, and my child’s 
heirs and assigns, for (a) any and all losses incurred as a direct or indirect result of personal injury, accident, illness, or death, and (b) 
any and all damage to or loss of personal property arising out of, relating to, or in connection with any the above‐named activities or 
trips or any trip‐related activity.  
   
WAIVER AND RELEASE FROM LIABILITY: On behalf of my child, myself, my child’s other guardians and my child’s heirs and assigns, I 
hereby assume all risks and waive, release, and forever discharge KIPP and its trustees, employees, agents and its related entities 
from any and all liability, actions, and damages of whatever kind, including, without limitation, general, special, compensatory and 
punitive damages, for personal injury, property damage, negligence or wrongful death arising out of, relating to, or occasioned 
wholly or in part by the activity or trip or any trip‐related activities. 
 
MEDICAL AUTHORIZATION: I hereby authorize any medical treatment deemed necessary while my child is participating in any 
activities referred to above. In the event of illness or injury, I authorize KIPP and each of its employees, representatives and agents 
to take such measures as are available and appropriate in the judgment of the persons taking such measures, and I consent to 
emergency medical treatment and care which may be deemed necessary to be rendered. KIPP will make reasonable efforts to reach 
me in the event of an emergency requiring medical care.  
 
I HAVE READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I ASSUME THE AFOREMENTIONED RISKS, AND AGREE TO THE 
WAIVER OF LIABILITY AND TO HOLD KIPP HARMLESS 
 
Student _______________________________________________________________________________  
 
                           
Signature of Parent/Guardian, Student (if over 18)    Date 
 
                           
(Print Name)              Emergency Telephone  

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 RELEASE FORM FOR MEDIA RECORDING
(Alumni under Age 18)

I, ________________________________________, do hereby agree that KIPP NYC through

College (KTC), its staff and agents, have the right to take photographs, videotape or digital recordings
of my child(ren) ___(See names below)___, as they participate in the KTC Program.

I do hereby release to KTC, its staff and agents all rights to exhibit photos, videotape or digital
recordings which may include images or sound recordings of my child(ren) in print and electronic
form. I understand that these materials may be used at the discretion of KTC for purposes relating to
its educational mission, including, but not limited to, explaining and promoting its program,
development and funding, recruitment and staff training. I understand that my child(ren) may be
recognizable in these materials, but will not be personally identified by name without my express
permission.

I understand that neither I nor my child(ren) will receive financial or other remuneration for use of
his/her/their images in photographs, videotape or digital recordings which are shown in any form of
media pursuant to this agreement.

This Agreement is effective with respect to the children listed below until they have reached their 18th
birthday. Children who have reached their 18th birthday will be asked to consent to this release on
their own behalf.

Minor Child #1 _____________________________________ KIPP School ________________

(PRINT NAME)

Minor Child #2_____________________________________ KIPP School ________________

(PRINT NAME)

Minor Child #3_____________________________________ KIPP School ________________

(PRINT NAME)

Parent/ Guardian Signature: __________________________________ Date: _____________