Complete the Entire Form – Do not alter the form in any manner.

Event________________________________________________    Date(s) of Event________________________

Name_______________________________________________________________________________________

Age_______                  ¨ Male ¨ Female         Birth date _________________

Social Security #___________________________________          County__________________________________

(Required for Medical Purposes)

Address______________________________________________________________________________________

City___________________________       State_________ Zip_________

Home#__________________      Work #______________________                       Cell #___________________

Insurance Co/Policy #______________________________________________

Insurance Co. Name:_______________________________________________

Insurance Co. Address:_____________________________________________

Insurance Co. Address & Phone #:____________________

Parent(s)/Guardian(s)________________________________________________________________________

EMERGENCY CONTACT:

Name___________________________________________________          Relationship_______________________

Home #___________________   Work #_____________________             Cell #______________________

Family Physician_____________________________________________

Office #_________________________    Home #______________________

PLEASE COMPLETE

For health or safety reasons, every person attending this event must submit a completed health form prior to the beginning of the program.  Please read and answer the following questions. Any “yes” response will require an explanation. 

1.         Will your child be bringing any type of medication to this event? ¨ Yes ¨ No ___________________________

2.         Does your child have any allergies? ¨ Yes ¨ No _______________________________________________

3.         Describe any special needs (medical, physical or mental challenges) we should be aware of?

 ____________________________________________________

4.         Does your child have any special dietary needs? _________________________________________________

5.         Date of last Tetanus immunization? ___________________

6.         May your child be given pain relievers (i.e., Tylenol, Motrin, etc.)? ¨ Yes ¨ No

If necessary, I do approve of officials taking my child, ________________________________, to the nearest doctor or hospital. I further understand that should health problem arise, I will be notified, but that if I cannot be reached by telephone, such medical treatment, including surgery, as deemed necessary by competent medical personnel, would be rendered.

EVENT ACCEPTANCE:

Education events and activities are coordinated by the University of Missouri 4-H Youth Development Programs. All participants must observe the following guidelines for conduct:  1. Participate fully in all sessions.  2. Show respect for property/facilities used during the event and assume financial responsibility for any damages they cause.  3. Observe the established agenda, including being in their own rooms at the announced curfew.  4. Appropriate and courteous behavior is expected. Swearing and obscene gestures are not permitted. All should be treated with respect and common courtesy. Participants are expected to dress appropriately. Clothing with alcohol or tobacco advertisements or sexual connotations, etc. is prohibited.  5. No alcohol, stimulants, non-prescription drugs or tobacco products will be allowed.

We understand and accept the responsibility for following the above guidelines, and understand that failure to do so will result in dismissal from the event or activity. Further, we accept financial responsibility for damages to property or materials, travel costs, and/or program costs which might result from violation of this agreement. We understand and agree that in consideration of the acceptance of my child in these activities, we release 4-H, the Curators of the University of Missouri, their respective officers, agents, and/or employees from all liability and loss (including court costs and attorney fees), resulting from any property damage, personal injury and bodily injury, including death, to me or my child in the course of these events. We will be bound by all rules and regulations while participating in said events.

Both youth and parent (guardian) must sign this form. If you choose to have this form notarized, the parent/guardian signature must be witnessed by the Notary Public. I understand if I do not have this health statement and consent form notarized, it could cause a delay in the treatment of my child.

_______________________________________________________________________________________________

Youth’s Signature                                                                                                                      Date

______________________________________________________________________________________________

Parent/Guardian’s Signature                                                                                                       Date

STATE OF MISSOURI, COUNTY OF_________________________

My Commission Expires: _____________________________________

Subscribed and sworn to before me on this _________ day of ____________________, 20_____.

_____________________________________________________________________________________________

Notary Public Signature

PHOTO POLICY:

Public Relations are an important part of the Missouri 4-H Program. Images (including photographs and video) are used in various print and electronic media to recognize members for their work and to let others know what is happening in 4-H. Should you prefer that your child’s image not be taken at 4-H events, we want to work with you to keep his or her image from being taken. Because there are so many youth involved in the 4-H program, we cannot assure you that your child’s image will not be taken. We will ask 4-H staff to honor individual requests Please visit with your children about your wishes and encourage them to let staff know that they request their images not to be taken. Should an image of your child be made and used against your wishes, please let us know so that we will not use it again in the future.

4-H/MU is an Equal Opportunity Institution. For concerns about access or opportunity, contact your local Extension Office or call 573- 882-7430. The University of Missouri – Columbia complies with the guidelines set forth in the Americans with Disabilities Act of 1990. If you have special needs as addressed by the Americans with Disabilities Act and need assistance with this or any portion of the enrollment process, call 573-882-2719. Reasonable efforts will be made to accommodate your special needs

                                                                                                         Revised January 2006 - Copy form as necessary.