Please read and complete all sections below. 

Please enter the name of the event(s) you are authorizing your child to participate in.

Name of Program(s) or Event(s) *

Date(s) *

Student's First Name *

Middle Initial

Student's Last Name *

Student Cell Phone

Student's Email *

Current School *
- Select Option Godwin Heights HS Innovation Central HS Ottawa Hills HS Southwest MS/HS Union HS Wyoming HS Burton MS Godwin MS Riverside MS Westwood MS Wyoming Jr High Not listed Please specify a value for Current School

Current Grade Level *
- Select Option 6th 7th 8th 9th 10th 11th 12th final year of middle college Not listed Please specify a value for Current Grade Level

First Name *

Last Name *

Parent/Guardian Cell Phone *

Parent/Guardian Alternative Phone

Email *

Full Name *

Phone Number *

Full Name *

Phone Number *

Is the minor child being treated by a physician for an injury, illness, or other medical condition? *
- Select Option Yes No

List all medical conditions that should be noted. (If not applicable, enter "NA.") *

List all medication the minor child is currently taking. (If not applicable, enter "NA.") *

If you need to have a dose of your medication during the trip, please bring it with you to self-administer in the presence of staff.

Please list any food allergies or dietary restrictions. (If not applicable, enter "NA.") We will try our best to make sure food that is appropriate for your child to eat is available, if possible. *

Reactions to allergies/conditions/concerns. (If not applicable, enter NA). *

If there are any steps that need to be taken to accommodate the child's medical condition(s), please list them here. (If not applicable, enter "NA.") *

All programs must establish a procedure for the pick-up and drop-off of Program Participants, specifying times and locations.  The Authorized Adults overseeing the pick-up and drop-off of Program Participants shall remain at the specified location until all minor children have been released.

TRIO ETS will share the specific pick-up and drop-off details with parents/guardians and students prior to each event.  Please note, TRIO ETS is not able to transport any students to or from their homes. Students wishing to take the city bus to or from a TRIO ETS event can request a bus pass from their TRIO ETS advisor.  Otherwise a parent or guardian will be expected to provide transportation for their son/daughter.

If a parent/guardian does not pick their son/daughter up after a trip or activity, and the student doesn’t have another way to get home, we will attempt to contact you via the phone number(s) you provided.  If we are not able to reach you, we will try to reach the emergency contacts you list above.  If we exhaust all other options and still cannot reach you, as a last resort we will contact GVSU Campus Safety Department and the police will assist us with trying to locate you.  

As the parent / legal guardian / foster parent of the minor child above, I certify that I have received, read, and understand the pick-up / drop-off and transportation procedures provided by the program.  If there are special arrangements that need to be made, I will inform the director of the program. 

I understand and agree to the transportation policy above. *
- Select Option Yes No

What form of transportation will the student take to the drop-off location, and to get home after the event? *
- Select Option Parent or guardian will transport the student Student will be driving themselves Student will be taking public transportation (no supervision provided on the bus or at the bus stop) Not listed Please specify a value for What form of transportation will the student take to the drop-off location, and to get home after the event?

Name of the adult responsible for transporting the student to and from the event (if applicable)

Phone number of the adult responsible for transporting the student to and from the event (if applicable)

Please read the following statements and sign below to give your consent.

As the parent, legal guardian, or foster parent of the minor child listed above, I hereby certify that the above information is the most up-to-date and correct to the best of my knowledge that I agree to the following as a condition of my child’s participation in the Grand Valley Stata University (GVSU) program or visit and/or related activities.

I give my permission to GVSU, St. Mary’s Hospital, Corewell (formerly Spectrum) Health, or other health care providers to provide, seek, obtain, or approve any routine, necessary, or emergency health care during the minor child’s involvement in the GVSU programs.  I understand that this authorization is given in advance of any specific diagnosis, or treatment or medical care being required and is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed advisable.  I understand my rights under the Health Insurance Portability and Accountability Acts (HIPPA) and authorize GVSU to release information as necessary for managing program health care.

I acknowledge that participation in the camp/activity/visit and related activities involves assumed and inherent risk of personal injury.  I assume such risk on behalf of the minor child and give my permission to the minor child to participate in all program activities.  I release and agree to hold harmless GVSU, its Board of Trustees, students, and employees from all claims, actions, damages and liabilities for personal injury or damage relating to or arising out of any activity except where the injury or damage is caused by the gross negligence of the University’s employees.  I understand that the minor child will be subject to the rules and regulations of the GVSU visit and related activity.  I understand that any person who repeatedly disobeys University policies or procedures will be immediately expelled from the program. 

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Minor Child's Name *

Program(s) or Event(s) *

Please read the following statement and sign below to give your consent.

The child/student listed above has my permission to participate in the program(s) or event(s) listed above.

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Please read the following statements and sign below if you agree.

I, as well as my child/dependent, understand that all students participating in special events and trips will be responsible in conduct to the driver and to adult chaperones at all times.

I will not hold my child's school district, Grand Valley State University, the TRIO Educational Talent Search Program, or any of their employees, volunteers or agents responsible for any injury to my child that occurs during any trip taken in good faith.  

I understand that GVSU is not responsible for lost or stolen property.

I have read this entire Minor Child Program Release Form and agree to release and indemnify the university. I fully understand it and I agree to be legally bound by it.

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Please read the following statements. If you agree to these terms (which are optional and not required for participation in events and trips) please sign below.

I, the Parent/Guardian of the above named student, hereby authorize Grand Valley State University and/or TRIO Educational Talent Search to:

1. Record my child's likeness and/or voice on a video, audio, photographic, or digital medium.
2. Use my child's name in connection with these recordings.
3. Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, internet) these recordings for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts.

I give permission to GVSU, to use, without charge and without reservation, my child’s likeness in any medium and for any lawful purpose, including promoting the University, its programs and services.  I waive any rights of action I may have and release GVSU and its licensees from any and all claims I may have arising from my child’s likeness, including the rights to sue for defamation or violation of my rights of privacy and publicity.

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If you do not want your child's photo taken, please contact our office at (616) 331-7111 or [email protected]. 

Refusal to sign the photo & video portion of the release form does not impact the minor child’s rights to participate.