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Liability Waiver Form
Required for all students participating in Homer Enrichment Hub programs

Instructions:

  1. Print this form
  2. Complete all sections
  3. Sign and date the form
  4. Return to Jeffrey Johnson at the next program meeting
  5. Or email a scanned copy to jjohnson47@alaska.edu

HOMER ENRICHMENT HUB

PARENTAL CONSENT, LIABILITY WAIVER, AND MEDICAL AUTHORIZATION FORM

IMPORTANT: This form must be completed, signed, and returned before your child can participate in any Homer Enrichment Hub programs.

PARTICIPANT INFORMATION

Child's Full Name:
Date of Birth:
Grade:
School:
Home Address:
City:
State:
AK
Zip:

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name:
Relationship to Child:
Primary Phone:
Secondary Phone:
Email:
Emergency Contact (if different):
Emergency Phone:

MEDICAL INFORMATION

Known Allergies:
Medical Conditions:
Current Medications:
Physician Name:
Phone:
Insurance Provider:
Policy #:

ACKNOWLEDGMENT OF PROGRAM INDEPENDENCE

I understand and acknowledge that:

The Homer Enrichment Hub is a COMPLETELY INDEPENDENT organization that is:

  • NOT organized by, affiliated with, sponsored by, or endorsed by Kenai Peninsula College or the University of Alaska system
  • NOT affiliated with the Kenai Peninsula Borough School District
  • NOT affiliated with the City of Homer
  • NOT affiliated with any school or facility where activities may occur

This program is organized by Jeffrey Johnson and Lia Calhoun acting in their PERSONAL CAPACITIES as private individuals. While they happen to be employed as professors at Kenai Peninsula College, this program is NOT a Kenai Peninsula College program and their employment there is mentioned only for identification purposes.

Parent/Guardian Initials:

ASSUMPTION OF RISK AND RELEASE OF LIABILITY

In accordance with Alaska Statutes 09.65.290 and 09.65.292, I acknowledge and agree:

1. ASSUMPTION OF INHERENT RISKS:

I understand that participation in educational and recreational activities involves inherent risks including, but not limited to:

  • Risk of physical injury during activities or movement between locations
  • Risk of exposure to communicable diseases
  • Risk of accidents during transportation to/from activities
  • Risk of allergic reactions or medical emergencies
  • Risks inherent in academic competitions and group activities

2. EXPLICIT WAIVER OF NEGLIGENCE:

I hereby RELEASE, WAIVE, DISCHARGE, AND HOLD HARMLESS:

  • Jeffrey Johnson and Lia Calhoun (as private individuals)
  • The Homer Enrichment Hub organization
  • Any volunteers or assistants working with the program
  • The University of Alaska system and Kenai Peninsula College
  • The Kenai Peninsula Borough School District and individual schools
  • The City of Homer
  • Any facilities hosting Hub activities

From ANY AND ALL LIABILITY, including liability for NEGLIGENCE, for any injury, death, damage, or loss sustained by my child or me arising from participation in Hub activities, to the fullest extent permitted by Alaska law.

3. INDEMNIFICATION:

I agree to INDEMNIFY AND DEFEND all released parties from any claims, demands, or causes of action, including attorney fees, arising from my child's participation.

Parent/Guardian Initials:

MEDICAL AUTHORIZATION

In the event of a medical emergency, I authorize program coordinators to:

  • Contact emergency medical services (911)
  • Provide or arrange necessary emergency treatment
  • Share relevant medical information with emergency responders

I understand that:

  • Program coordinators are not medical professionals
  • The program does not provide health or accident insurance
  • All medical costs are my sole responsibility
  • Coordinators will not administer medications
Parent/Guardian Initials:

PROGRAM RULES AND CONDUCT

I understand that my child must:

  • Follow all program rules and behavioral guidelines
  • Respect coordinators, volunteers, and other participants
  • Care for facilities and equipment

I acknowledge that violation of program rules may result in removal without refund (if fees apply).

Parent/Guardian Initials:

PHOTOGRAPHY RELEASE

YES - I grant permission for my child to be photographed/recorded for program documentation and promotion
NO - I do not grant permission for photography/recording

CERTIFICATION AND SIGNATURE

I CERTIFY THAT:

  • I am the parent or legal guardian with authority to sign this form
  • I have read and understood all provisions of this waiver
  • I understand this is an independent program not affiliated with any educational institution
  • I am signing this form voluntarily and without inducement
  • All information provided is accurate and complete
  • I understand this waiver is binding on me, my child, and our heirs

THE TERMS OF THIS WAIVER SHALL BE EFFECTIVE FOR THE ENTIRE 2025-2026 ACADEMIC YEAR

Parent/Guardian Printed Name:
Date:
Parent/Guardian Signature:
Child's Signature (if 13 or older):
Date:

Return this form to:

Homer Enrichment Hub
c/o Jeffrey Johnson
[Independent Program Coordinator]
Email: jjohnson47@alaska.edu

Note: Email address provided for identification purposes only. This is not a Kenai Peninsula College program.

Form Version 1.0 - August 2025

    Homer Enrichment Hub