Race

Pick Up Information

In addition to the parent/guardian(s) and emergency contacts listed, please list the names of up to two additional people authorized to pick up the

above referenced child. These individuals will not be contacted in case of an emergency, the parent/guardian(s) or emergency contact information

will only be used. If an individual who is not listed on this form is permitted to pick up your child/children, the parent/guardian(s) will need to

provide written permission (letter or email) to Extension personnel or approved volunteer responsible for the event/activity.

Military Service (if none, skip this section)

Health History

Does the participant have, or at any time has had, any of the following? Check “Yes” or “No” to each item. Please explain any “Yes” answers (noting the number of the item) in the space below or on an additional sheet if necessary. Reporting conditions allow Extension personnel and approved volunteers to best support your young person and will be kept confidential.

Allergies

The following over the counter medications may be administered to my child without contacting me:

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 & 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.

PERMISSION TO PARTICIPATE

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.

PUBLICITY 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.