Parent Guardian Release form

Parent/Guardian and Student Certification/Release Form

Student Name:

High School

Program:

DCSC/MATC

Course Enrolled:

P/G Initial

I understand that all tuition/fees/textbook costs for any coursework through the Youth Apprenticeship

Program will be covered by the school district. I also understand that if my child does not successfully complete the

course I may be required to reimburse the school district for the costs associated.

I understand that a parent or guardian shall attend, along with my child, any orientation session that

may be required for the work-based learning program.

I authorize DCSC to text my child when needed for DCSC programming

I authorize instructional staff (Madison College/UW/DCSC) to release grade/performance information to DCSC staff

for courses related to this program, to be distributed to our high school. (FERPA release)

I authorize my child’s high school and the DCSC office the use of the following; written/oral testimonials,

photographs and/or video or digital recordings with my child’s image, in publications and/or news releases.

I, the undersigned, do hereby grant to the Wisconsin Department of Workforce Development ("DWD"), and all those acting

under its permission or authority, the right and license to copyright, reproduce and/or publish at any time, in print, broadcast,

electronic or other media, the photographic images, video and audio recordings, and use them for any such purposes. I

acknowledge that the images, recordings and interviews are “works-made-for-hire” so that DWD owns all right, title and interest

therein; provided, however, that if any of the images, recordings or interviews cannot be considered a “work-made-for-hire,” I

hereby assign, transfer and convey to DWD sole and exclusive ownership therein.I waive any claim to financial remuneration for

any such use. I also waive any right to inspect or approve the finished product. I hereby release DWD, its legal representatives,

and all persons acting under its permission or authority, from any liability relating to the use of the images, recordings and

interviews described above, and also for any blurring, distortion, alteration, optical illusion, or use in composite form, whether

intentional or otherwise.

I understand that I am solely responsible for transportation of the undersigned student to and/or from the

program’s classroom and/or worksite and for all loss involved in said transportation. I certify that my child, if driving

to and from the classroom or worksite, has a valid driver’s license and adequate car insurance. I give permission for

my child (“student”) to be transported in a motor vehicle contracted by DCSC. My child is expected to follow all

applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver

and/or other adult volunteers.

I understand that my child’s participation in this program is voluntary. Please use your judgment in which jobs to apply for,

interview for, and accept. We recommend that you do research on each company before applying , talk with a trusted adult

about the company and the position before accepting a job offer. By signing below, the Parent/Guardian agree to indemnif y and

release the Dane County School Consortium, Participating Districts, and its elected officials and/or its employees from any and

all liability, and any and all damages and/or injuries to the student’s person or property as a result of participating in this

program.

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 a DCSC staff member or partner and I am

not reasonably available by telephone to give consent.

Please list any medical concerns that DCSC instructional staff should know about your child:

Unless signed by a parent or guardian below, I declare that I am of legal age and have every right to contract in my

own name in relation to this matter.

Student signature:

Date:

Parent signature:

Date:

The Dane County School Consortium does not discriminate on the basis of sex, race, color, national origin, ancestry, creed, pregnancy, religion, marital or parental status, sexual

orientation, or disability. Inquiries related to Section 504 of the Rehabilitation Act of 1973, s.118.13, Wisconsin Statutes, or Title IX of the Education Amendments of 1972 should be

directed to the home school non-discrimination officer or to the Dane County School Consortium Director at 608-316-1358.