Military Service (if none, skip this section)
Heath Section
The following over the counter medications may be administered to my child without contacting me:
Conditions:
Communication
I acknowledge and agree that, although my child may participate in 4-H programs delivered in school settings, the University of Kentucky Cooperative Extension Service is a separate entity from my child’s school and school district. I understand and agree that employees and approved volunteers of the Cooperative Extension Service may communicate electronically with my child outside the school’s traceable communication system regarding 4-H clubs, programs, activities, and events following guidelines established by the University of Kentucky, state, and federal regulations for the Land Grant Cooperative Extension Service.
Review Confirmation Signature
All information provided on this form is correct and complete to the best of my knowledge. This person has permission to engage in all events and activities. I hereby give permission to the event designee to provide routine health care, administer prescription and over the counter medications as noted and seek emergency medical treatment if warranted. I agree to the release of all records necessary for medical treatment, billing, or insurance. In the event I cannot be reached in an emergency, I give permission to the attending physician to secure and administer treatment, including hospitalization.
Survey and Evaluation Release
I hereby establish my willingness to participate as an adult (i.e., 4-H leader, other volunteer, parent/ guardian, site manager, etc.) and give permission for my child (under 18 years of age) to complete surveys and evaluations that will be used to determine program effectiveness or to promote the program. I understand that participation in surveys and evaluations is voluntary and that my child and I may choose not to participate and may withdraw from surveys and evaluations without impact on my or my child’s eligibility to participate in the 4-H program. I understand that my child or I may be asked for consent before completing a survey or an evaluation
I acknowledge that my child is participating in 4-H programs for their own personal benefit and that my child will participate in recreational and other activities as part of 4-H programs. I understand that some activities may have inherent dangers and physical risks and that no amount of care, caution, instruction, or expertise can completely eliminate them. I assume responsibility for all risks, known and unknown, involving my child’s participation in 4-H programs and I voluntarily authorize my child’s participation in reliance upon my own judgment and knowledge of my child’s experience and capabilities. I hereby agree to indemnify and hold harmless the University of Kentucky Cooperative Extension Service and all related parties from any liability, losses, costs, damages, claims, or causes of action of any kind or nature arising from or related in any way to my child's participation in 4-H program.
Photo Release:
I hereby grant the 4-H program, University of Kentucky and their agents, the right to use, reproduce, assign, and/or distribute still pictures, video, and sound recordings of myself or my minor child without compensation for use in promotion, advertising, educational publications or online content.