Clover Kids
with Iowa State University Extension and Outreach
Clover Kids Full Name
*
First Name
Last Name
Parent/Guardian Full Name
*
Parent/Guardian #1
Parent/Guardian #2
Parent/Guardian Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone
*
Please enter a valid phone number.
Emergency Contact Full Name
*
Emergency Contact #1
Emergency Contact #2
Emergency Contact Phone #1
*
Please enter a valid phone number.
Emergency Contact #2
Please enter a valid phone number.
At which location will your child be attending:
*
Clay Central - Everly
Everly Public Library
Iowa Great Lakes Lutheran
Sacred Heart
Spencer Public Library
Sioux Central
Clay County Extension
How is your child arriving to the next destination:
Pick up by parent/guardian.
Walk
Aftercare
Other
I understand that my child must be healthy and reasonably fit in order to safely participate in 4-H recreation activities and that I will inform the program leader(s) of any medication, ailment, condition, or injury that may affect his/her ability to participate safely. Please describe any allergies, dietary, or medical concerns.
*
MEDICAL EMERGENCY PRARENTAL PERMISSION
The health history for my child is correct and complete to my knowledge. If an injury or other medical condition occurs or arises, I hereby give permission to the ISU Extension staff or volunteer to provide routine first aid and seek emergency treatment including x-rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing or insurance purposes. I understand that I am financially responsible for charges to the attending physicians or health care unit (other than those covered by an ISU Extension accident insurance plan). In the event of an emergency where I cannot decide for my child, I give permission to the physician/hospital selected by the ISU Extension staff or volunteer to secure and administer treatment for my child, including hospitalization. (*If you cannot sign this section of the form for any reason, contact the County Extension Director regarding a legal waiver in order to attend and participate.)
PUBLICITY/ IMAGE/ VOICE PERMISSION
The Iowa State University Extension 4-H Program normally takes photographs, video, and/or tape recording of our programs. During activities, a photograph or video/audio recording may be taken of you or your child. Unless you request otherwise, your initial below will be considered permission for Iowa State University and the 4-HProgram to photograph, film, audio/video tape, record and/or televise your image and/or voice or the image and/or voice of your child for use in any publications or promotional materials, in any medium now known or developed in the future without any restrictions. If you object to ISU using you or your child’s image or voice in this manner, please notify the 4-H program leader.
ASSUMPTION OF RISK AND RELEASE OF LIABILITY
I give permission for the youth named above, to participate in the 4-H program. I understand that 4-H club project activities/events may involve certain risks of physical activity and possible injury and that Iowa State University and its 4-H program will provide each participant with reasonable care, but that ISU cannot guarantee that my child will remain free of injury. In addition, some 4-H projects including but not limited to: shooting sports, horse or livestock projects, water activities, and other sporting activities have a higher degree of risk. I nonetheless wish to have my child participate as an Iowa4-H club member in the 4-H club program and ASSUME the RISK of participating. I agree to RELEASE from LIABILITY, INDEMNIFY and HOLD HARMLESS the State of Iowa, the Board of Regents of the State of Iowa, ISU and ISU Extension and their officers, employees and agents (hereinafter the RELEASEES) from any and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my child’s participation in the 4-H program. This release, however, is not intended to release the above-mentioned RELEASEES from liability arising out of their sole negligence.
By checking this box and submitting this form, I agree that:
*
I HAVE READ THIS AGREEMENT IN FULL, AND I UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
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