(Person to contact in the event that either parent/guardian cannot be contacted)

I verify that the above information is correct, and I understand that completion of this form does not guarantee placement in the Georgia’s Pre-K Summer Program. If my child is placed in the Summer Program, I agree that my child will attend the program for 6.5 hours each day, 5 days a week, for 6 weeks. I understand that failure to comply with these attendance requirements could result in disenrollment. I understand that I must provide all the necessary documentation for my child to be enrolled in the program.

I verify the above information to be correct and true. I hereby grant permission for the information provided in the preceding Registration Form to be distributed to the Pre-K provider, the Department of Early Care and Learning (DECAL), and certain agencies or entities contracted by the Pre-K provider or DECAL, including but not limited to the Georgia Department of Education and colleges/universities.

I hereby grant permission for the Pre-K provider specified below, the Georgia Department of Early Care and Learning (DECAL), and certain agencies or entities contracted by the Pre-K provider or DECAL, including but not limited to the Georgia Department of Education and colleges/universities, to record the participation and appearance of my child, by photograph and/or videotape in connection with daily Pre-K activities for the purposes of news releases, reporting, and assessing the progress of children and the program. DECAL and its contractors are authorized to exhibit or distribute such photograph(s) and/or videotape in whole or in part without restrictions or limitations for any educational or promotional purpose that DECAL deems appropriate. Such photograph(s) and/or videotape may, for example, appear in printed or visual materials for DECAL and/or on DECAL’s website. The undersigned hereby jointly and severally releases, acquits, forgives, and discharges the Pre-K provider, DECAL, and other entities contracted by the Pre-K provider or DECAL, from any actions, agreements, claims, controversies, demands, judgments, liabilities, proceedings, and suits, whether arising in equity or in law regarding such participation and appearance by said child. This release shall remain binding upon all successors in interest and personal representatives of the parties, to the extent permitted by law.