Parent Authorization Form


Student's Name  

Current Grade  

School  

Guardian's Name  

Address  

City  

State  

Postal Code  

Guardian's Phone Number  

Number of Members in Household  

Allergies to drugs or foods  

Special Medications, Blood Type, or Pertinent Information  

Student's Physician  

Preferred Hospital  

 

Consent for Overnight Accommodations
I certify that that I am the parent or legal guardian of the student listed above. I do hereby consent for this student to stay overnight at the LC Valley Youth Resource Center at 1633 10th Avenue, Lewiston, Idaho.

Hours of Operation
I understand the LC Valley Youth Resource Center Inc closes at 8:00 am Monday through Friday and at 10:00 am on Saturday and Sunday.

Transportation Release
I understand LC Valley Youth Resource Center Inc does not provide transportation. I acknowledge all transportation will be the responsibility of the guardian. If transportation is not available, I grant and authorize LC Valley Youth Resource Center Inc permission to provide bus tokens to the student.

Consent to Release Student
I understand the student listed above has chosen to be present at the LC Valley Youth Resource Center at 1633 10th Avenue, Lewiston, Idaho. I further understand if the student chooses to leave the facility at 1633 10th Avenue, the student will be allowed to leave at any time. If the student chooses not to comply with LC Valley Youth Resource Center Inc safety policies, these actions will be considered a choice not to remain at the LC Valley Youth Resource Center and the student will be required to leave the property. I hereby grant and authorize the LC Valley Youth Resource Center to release the student at any time. The LC Valley Youth Resource Center will not be held responsible for the student's actions once they leave the facility at 1633 10th Avenue, Lewiston, Idaho.

Liability Release 
I hereby release, indemnify and hold harmless LC Valley Youth Resource Center, its officers, directors and employees, and the organizers, sponsors and supervisors of all LC Valley Youth Resource Center activities from any and all liability in connection with any injury my child may sustain (including any injury caused by negligence) in conjunction with staying at the LC Valley Youth Resource Center.

Consent to Video Surveillance
I understand the LC Valley Youth Resource Center utilizes a 24-hour video monitoring system in all rooms, excluding restrooms. I hereby grant and authorize the LC Valley Youth Resource Center Inc to record video of the student listed on this form while on the premises at 1633 10th Avenue, Lewiston, Idaho.

Consent to Treat Minor Child
I certify that that I am the parent or legal guardian of the student listed above. I do hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is under the care of Michelle King or Edgar King of Lewiston Idaho and I am not reasonably available by telephone to give consent. This authorization is effective for 365 days from the signature date on this form.

Authorization for Exchange of Confidential Information with Lewiston Independent School District No. 1 and Clarkston School District.

(This form allows information about your student to be exchanged.)
I authorize Michelle King, President, LC Valley Youth Resource Center at 1633 10th Avenue, Lewiston, ID 83501 to obtain information from Lewiston High School, Clarkston High School, Jenifer Junior High School, Lincoln Middle School, Sacajawea Junior High School, Lewiston School District, and Clarkston School District.


By signing this authorization, I understand that the parties named above are permitted to exchange written and verbal information regarding my child with Lewiston and/or Clarkston School District. This includes official school records, transcripts, teacher/counselor/staff observations, social work reports, and counseling records.


This authorization is for the purpose of providing information for the care of my child at the LC Valley Youth Resource Center.
The parties also accept a photocopy of this release form and give it the same full force and effect as the original. I further understand that I may revoke this authorization in writing at any time by providing a copy of my revocation to the parties named above. The information used or disclosed under this release might be disclosed by the school district as an education record pursuant to FERPA and might no longer be protected by HIPAA.

I give CONSENT for the bidirectional exchange of information.

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LC Valley Youth Resource Center https://lcvyrc.org
Signature Certificate
Document name: Parent Authorization Form
lock iconUnique Document ID: 34a43160b13edb62fc6948d593aa54aa378d5599
Timestamp Audit
September 20, 2020 9:08 pm PDTParent Authorization Form Uploaded by Michelle King - lcvyrc@gmail.com IP 96.18.75.208
September 20, 2020 9:16 pm PDTMichelle King - lcvyrc@gmail.com added by Michelle King - lcvyrc@gmail.com as a CC'd Recipient Ip: 96.18.75.208