RE>DIRECT After School Program

I, the undersigned, do hereby authorize the school district listed above to disclose and deliver the complete education records maintained under the above student's name including but not limited to the following: active parent login, grades, transcripts, school health records, psychological and educational testing, special education records, verbal information, and discipline. The information should be delivered to C2k Ministries Inc, 1138 Township Road, Merigold, MS 38759 for the purpose of the RE>DIRECT After School Program for the purpose of planning and advocacy. My authorization for the use, disclosure and/or redisclosure of the information identified above is voluntary. I understand that the information to be disclosed or redisclosed may include individually identifiable health information. I understand that, upon my request, I am entitled to a signed copy of this authorization form and the records to be disclosed. Unless sooner terminated in writing, this release shall remain effective for the academic year in which it is signed. A copy of this release shall be sufficient to authorize release of information identified above as the original signed by me.

I, the Parent/Guardian listed above for the student(s) listed above, residing at the residence address above, and in the state listed above, herein authorize the adult sponsor of the RE>DIRECT After School Program to consent to any x-ray, examination, anesthetic, medical or surgical supervision and on the advice of any physician or surgeon licensed to practice in the state of treatment, when such treatment is immediate, and when efforts to contact me are unsuccessful. By signing (typing below), I understand that I am giving C2k Ministries the authority to make emergency health decisions for my student(s) provided they cannot reach me.

I, the undersigned, certify that I am the parent or legal guardian of the minor child(ren) named above. I hereby give my permission for my minor child to participate in the RE>DIRECT After School Program, hereafter referred to as "Program". I give my consent to have my minor child given achievement tests, as well as, behavior assessments in an effort to better understand how to help my child behaviorally and academically. I also understand that the assessment results will not be shared with anyone without my prior consent. I recognize that there are risks involved in participating in the Program which might include, but are not limited to: recreational activities, educational activities, field trips and interacting with other individuals and groups; and there is always the risk of incidental loss, injury, harm, damage, or death to my minor child in connection with his/her participation in the Program. To the fullest extent permitted by law, I wholly release C2k Ministries, Inc., its board of directors, officers, employees, agents, volunteers, and representatives from any loss, injury, harm, damage, death, or property damage which may occur to my minor child while participating in the Program and agree to save and hold harmless C2k Ministries, Inc., its board of directors, officers, employees, agents, volunteers, and representatives from any claims arising out of my minor child's participation in the activity. I hereby authorize C2k Ministries, hereafter referred to as "Company," to publish photographs and videos taken in connection with the Program of myself and/or the minor child listed below, and our names and likenesses, for use in C2k Ministries, Inc.'s print, online and video-based marketing materials, as well as other Company publications. I hereby release and hold harmless C2k Ministries, Inc. from any reasonable expectation of privacy or confidentiality for myself and for the minor child listed below associated with the images specified above. Further, I attest that I am the parent or legal guardian of the child listed below and that I have full authority to consent and authorize C2k Ministries, Inc. to use their likenesses and names. I further acknowledge that participation is voluntary and that neither I, nor the minor child, will receive financial compensation of any type associated with the taking or publication of these photographs, videos, and likenesses or for participation in Company marketing materials or other Company publications. I acknowledge and agree that publication of said photos, videos, and likenesses confers no rights of ownership or royalties whatsoever. I hereby release C2k Ministries, its contractors, its employees and any third parties involved in the creation or publication of Company publications, from liability for any claims by me or any third party in connection with my participation or the participation of the minor child listed below. By signing (typing below), I, the undersigned, understand the permission, liability, and media waivers.