2024 Omaha Zoo Trip

Participant Name*

First NameLast Name

County 4-H'er is enrolled*

Grade*

Gender*

MaleFemale

Bus Pick up Location*

BooneAmesMarshalltown

Bus Drop Off Location*

BooneAmesMarshalltown

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

PERMISSION AGREEMENT, RELEASE AND WAIVER OF LIABILITY

I give my permission for the above named individual to participate in the Omaha Zoo Overnight Safari Trip. I hereby RELEASE FROM LIABILITY, IMDEMNIFY, and HOLD HARMLESS the State of Iowa, Board of Regents of the State of Iowa, Iowa State University, ISU Extension and Outreach, and Boone County Agricultural Extension District and any of the officers, servants, agents and employees of the above-mentioned entities (hereinafter referred to as RELEASEES) for any liability, claim and/or cause of action arising out of or related to any loss, damage or injury, including death, costs or other expenses or liabilities incurred by me and anyone accompanying me, (including minors I am responsible for during this event), that occurs as a result of my or my child’s voluntary participation in this program. This release, however, is not intended to release the above-mentioned RELEASEES from liability arising out of their sole negligence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Omaha Zoo Overnight Safari Trip Registration

Participant Information