Washington State 4-H Youth Authorizations/Health Form

Washington State 4-H
Youth Authorizations/Health Form
Youth’s Name: First __________________________ Mid. Init. ____ Last _____________________________________
Effective 4-H Year October 1, 2015 - September 30, 2016
Assumption of Risk
I understand that there are risks in participating in 4-H Youth Development events and activities associated with Washington State University
In consideration for and as a condition of being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks
that exist, including the risk of death or injury to my child or self or loss or damage to my property. I understand that there may be risks that WSU
cannot predict or foresee, and I also assume full responsibility for those risks.
Membership in the 4-H Youth Development Program may involve participation in a wide variety of activities such as, but not limited to: club
meetings, shows, clinics, working with animals, physical education activities, water-sports, food preparation, woodworking, crafts, and travel. Risks
in participating include, but are not limited to: temporary or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or
cartilage damage, orthopedic damage, head, neck, or spinal injuries, loss of use of arms and/or legs, eye damage, disfigurement, burns, drowning
or death. I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of traveling to or
from the 4-H Youth Development Program activities that cannot be specifically listed. Further, I recognize that the actions of other participants in
the activity may cause harm or loss to my child, self or property.
Consent Agreement: I have read, understand and consent to the foregoing statements. I am the parent or guardian of the child (minor under the
age of 18, or other person legally incompetent to contract), whose name is set forth OR I am an enrolled youth or adult over the age of 18.
Parent/Guardian Signature: _____________________________________________
Date: ________________________
Youth Signature (if over age 18): _________________________________________
Date: ________________________
Youth Code of Conduct
The code of conduct shall be signed by each youth member and parent/guardian with the current year enrollment. A 4-H youth is not eligible to
participate in the 4-H program without this agreement.
As a 4-H youth participant/member you have the responsibility of representing all 4-H members to the public. Therefore, you are expected to
conduct yourself in a manner that respects individual rights, safety and property of others, and reflects favorably on your state, county and club, as
well as yourself. You are expected to observe the following guidelines.
1. The possession and use of alcoholic beverages, marijuana, and/or drugs other than prescribed medication is prohibited. Use of tobacco
products by youth members is prohibited.
2. Obscene and discriminatory language, rough housing, and insubordination will not be tolerated.
3. Members and leaders must demonstrate respect for each other and the public.
4. Display of overly affectionate attention between individuals is prohibited.
5. Damage to, or destruction of property belonging to others is prohibited.
6. Animal abuse of any kind is prohibited.
7. Display of unsportsmanlike conduct is prohibited.
8. Be an example of how to accept what life has to offer - good and bad - and how to live with the outcome of exhibiting your project.
9. Wear neat, clean and appropriate attire; including shoes, boots, or appropriate footwear at all times.
Report any infractions to the superintendent/club leader/event coordinator.
Penalties for infractions(s) may include any or all of the following:
• Placing the member on probation for involvement in further 4-H events and/or termination of 4-H membership.
• Assessing the member the cost of damages and repairs in the event of damage or destruction of property.
• Releasing the member to the nearest law enforcement agency and/or the proper authorities.
• Withholding premiums and/or sending the member home from 4-H activities or events.
Parents/guardians will be notified if penalties are necessary.
For members and parents/guardians: We understand this agreement is to ensure the safety of the 4-H youth member and ensure conduct and
behavior that will result in each participant receiving the full benefit of enjoyment and educational experience from this 4-H affiliation/event. It is
not intended to place undue restrictions upon participants.
For youth members: I have read the Code of Conduct and agree to abide by its rules. I understand that infractions of this code will result in any or
all of the penalties listed above.
For parents/guardians: I have read the code of conduct and understand that I am responsible for my child or ward's behavior. I give permission to
the staff in charge to administer the code.
I understand that the WSU Extension County 4-H program may have policies that are more restrictive than the state policies, but not less
restrictive. In the event that the County 4-H program has additional agreements required for enrollment, a hard copy form will be provided for
Yes, we agree
Youth Member Signature _____________________________________________
Date: ________________________
Parent/Guardian Signature ____________________________________________
Date: ________________________
Indemnity Agreement
I, my heirs and assigns, hereby release, the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers,
employees/volunteers, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses to person or property, which I may
sustain and/or sustain as a result of death or injury, as a result of or connected with participation in this program and/or event. If any part or
portion of this Release of Liability is determined to be invalid or unenforceable, the remaining parts or portions shall be enforceable. This release
and all matters related to your activities involving Washington State University shall be governed by and interpreted in accordance with
Washington law. I have carefully read this document, understand its contents and am fully informed about this program and circumstances. I am
aware that this document is a contract with WSU and the program sponsors. I enter this contract freely and voluntarily.
Parent/Guardian Signature ____________________________________________
Date: ________________________
Publicity/Media Release
I understand that, unless noted below, photos, video, or audio recordings made of me or my enrolled child/ward at 4-H events may be used by
WSU Extension and Washington State 4-H, without compensation, to promote the 4-H Youth Development Program. I understand that my name
may be revealed in descriptive text or commentary. (Select one):
 Yes, we agree
 No, we do not agree to use of digital images or voice recordings as set forth above.
Youth: Surveys & Evaluation Permission
Written Notice of Passive Consent: As a participant in the 4-H Program you or your child may be asked to help with the evaluation of the program
to tell us how well the program is working. You or your child may be asked to complete a written survey about what you/they learned from
participating in the program.
Participating in the evaluation is not required if you or your child decide not to participate, it will not affect participation in this or future WSU
Extension programs. If you or your child do not want to answer some questions on the survey, that is okay. The survey responses will be
anonymous, and participant responses will not be identified in any way.
If you or your child do not want to participate in the evaluation of the 4-H Program or you have questions about any evaluation, please contact
your WSU County Extension Office.
Health Information Form
Please be as accurate, yet concise. In the event of an emergency, this may be the only immediate source of information.
*Indicates required fields.
General Health
*Does this participant have any health diagnosis that is important for program staff to know in order to maximize participation and ensure safety
and well-being? (Select one):
 None
 Yes, a physical disability, a learning disability, behavioral disorder, and/or mental diagnosis.
Health diagnosis details/explanations & suggested accommodations:
Dietary Needs
*Does this participant have any specific dietary needs? (Select one):
 None
 Yes, food allergies or restrictions (e.g., peanuts, gluten-free) or food preferences (e.g., vegetarian).
Dietary needs details/explanation:
*Does this participant have any allergies or reactions to drugs or things in nature? (Select one):
 None
 Yes, allergies or reactions to drugs or things in nature.
Describe any allergies and/or reactions:
*Does this participant have any conditions requiring medication? (Select one):
 None
 Yes, and assistance is needed with medications.
 Yes, and this participant is capable of self-administering medications.
Medication details/explanation:
*Immunizations (Select one):
 I understand and accept the risks to my child from not being fully immunized.
 My child is up-to-date on his/her immunization and tetanus shots as required by Washington State law.
Additional Information
Please provide, in the space below, any additional information about the youth participant that may affect his/her ability to fully participate in the
4-H program:
Additional information:
Health-Care Providers/Insurance
Health-Care Provider(s)
*Primary Doctor: ______________________________________________
*Phone: (_ _ _) _ _ _ - _ _ _ _
Additional Doctor: _____________________________________________
Phone: (_ _ _) _ _ _ - _ _ _ _
Medical Alerts: _______________________________________________
Medical Insurance Information (Select one):
*I am covered by family medical and/or hospital insurance:
 Yes
 No
Primary Insurance Company: _____________________________________________ Policy Number: __________________________
Subscriber: ___________________________________________________________ Insurance Co. Phone#: (_ _ _) _ _ _ - _ _ _ _
Emergency Contact Information (if Parent/Guardian cannot be reached)
*Contact Name (Non-Parent/Guardian): ____________________________________________ *Primary Phone: (_ _ _) _ _ _ - _ _ _ _
Alternate Phone: (_ _ _) _ _ _ - _ _ _ _
*Relationship to Participant: _____________________________________________
Emergency Medical Release
In an emergency requiring medical attention or a situation reasonably believed to be an emergency by Washington State University (WSU)
authorized agents including enrolled 4-H volunteers or event staff, I authorize WSU and its authorized agents to obtain emergency medical care for
my child. I will be responsible for any expenses incurred in so doing including, but not limited to, care by health care professionals, hospital care,
and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my child’s health record from providers
who treat my child and these providers may talk with the program’s staff about my child’s health status.
Note: Minors may consent to certain services in Washington.
I hold harmless and agree to indemnify Washington State University, its authorized agents, and employees from decision to seek emergency
*Parent/Guardian Signature ____________________________________________
Date: ________________________