New Jersey 4-H Release/ Agreement Form for Adults

4H103
New Jersey 4-H Release/
Agreement Form for Adults
Both sides of this form must be completed and signed by all adults participating in 4-H overnight activities, field trips, and events
requiring group transportation where youth are present, or any other events sponsored through the 4-H Youth Development Program
as determined by the event coordinator. The form should be submitted prior to the event.
Information about the Adult Participant and Activity
Name of Adult participant: ____________________________________________________________________________________
Address: _______________________________________________
City:__________________ State:_______Zip:___________
Telephone number: _____________________________________
Email Address: ___________________________________
4-H county: _______________________________
Have you gone through the appointed volunteer process?
Yes
No
Name of activity/event: _______________________________________________________________________________________
Name of 4-H group sponsoring or participating in this event: __________________________________________________________
Location of event: ___________________________________________________________________________________________
Date and time of participation of individual named above: ___________________________________________________________
Release of Liability
Although Rutgers Cooperative Extension and its event coordinator(s) will use the utmost precaution in guarding the health of all
participants and preventing accidents, I release them from any liability in case of injury as a result of this activity. Furthermore, I
release the owner and driver of the car transporting me to and from this event, from any liability in the case of illness or injury.
Sign Here
Signature of adult participant ___________________________________________________________________
Medical Emergency Authorization and Health Information
In case of sudden illness or an accident to myself requiring immediate treatment or surgery while I am a participant in this activity, I
authorize the 4-H event coordinator or other adults present to take such action as seems appropriate to protect my health and physical
well-being. This authority extends to any physician(s) and/or surgeon(s) selected to perform medical and/or surgical procedures
including examinations and tests necessary to preserve my life and well-being. All efforts will be made to contact the individual
named as my emergency contact above in case of emergency.
___________________________ _____________________
Name of emergency contact
Phone number
__________________________________ __________________
Name of additional emergency contact
Phone number
The following information is provided as an aid to the event coordinator in dealing with my well-being. I have the following
conditions (include allergies, handicaps, diabetes, pregnancy, asthma, medications needed, etc.):
Health conditions: ___________________________________________________________________________________________
Medications/Instructions: _____________________________________________________________________________________
Health Insurance: Company Group# ___________________________________ ID# ______________________________________
Sign Here
Signature of adult participant ___________________________________________________________________
Continued on other side
New Jersey 4-H Code of Conduct
The primary purpose of the New Jersey 4-H Code of Conduct is to ensure the safety and well-being of all
participants at 4-H sponsored events and activities. It applies to all participants, with participants defined as 4-H
members, their parents, and volunteers.
As a participant in the 4-H program, I will:
• Conduct myself in a courteous manner and treat members, parents, 4-H volunteers, Extension staff, judges and
others with respect. Appropriate language and behavior are expected at all times.
• Respect and adhere to the rules and guidelines of the 4-H program including all those specific to a 4-H event or
activity.
• Uphold an individual’s right to dignity by supporting an environment of inclusion which welcomes involvement
of participants from all backgrounds.
• Accept supervision and support from county and state 4-H staff while participating in the 4-H program. This
includes acceptance of supervision and support from appointed 4-H volunteers coordinating 4-H events and
activities.
• Obey local, state and federal laws.
Participants who fail to adhere to the New Jersey 4-H Code of Conduct are subject to a range of disciplinary
actions. Such actions will be taken in compliance with the New Jersey 4-H Discipline Policy and Procedure.
When appropriate, immediate corrective action will be taken at the 4-H event to ensure the safety and welfare of
all participants.
I understand if I fail to adhere to the above Code of Conduct, I will be subject to disciplinary action and
potentially prohibited from attending and participating in the New Jersey 4-H Youth Development program.
Sign Here
________________________________________________
Signature of participant
____________________________________
Date
New Jersey 4-H Media Policy and Release
The 4-H program routinely promotes activities through various media. This includes, but is not limited to newsletters, newspapers,
brochures, and displays. In doing so, the names and photos of members may be included to help tell the 4-H story. However, New
Jersey 4-H policy is that on web sites, youth in photos will not be identified by name(s).
❑ No, do not use my individual picture for any purpose. I will make an effort to avoid opportunities to be in group photos.
❑ No, do not use my name for any purpose.
Revised: January 2013