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OK 4-H Youth Enrol ment Form 4-H Year: 2016-2017 Complete EACH set of blocks labeled REQUIRED. Incomplete information wil require returning the enrol ment form and delay enrol ment status as an active enrol ment.
oYES Make any necessary changes to the family information before continuing with Family Information: Was your family al required fields.
enrol ed last year? oNO New family to 4-H. Complete ALL required fields.
Family Profile Last Name Family Primary Phone Number City and Zip Code Family Correspondence Preference Are you in a Military 4-H Club? Na oEmail oPostal Mail Youth's First & Last Name Was this YOUTH enrol ed last year? 4-H Member/Cloverbud Email REQUIRED Mailing Address if different from Family Birthdate MM/DD/YYYY Gender: oMale oFemale City and Zip Code Primary Phone if different from Family Youth's Correspondence Preference oEmail oPostal Mail Youth's Cel Phone MUST provided CELL PROVIDER to receive text messages (ATT, Horizen. ) Parent/Guardian #1 First Name Work Phone and Extension Parent/Guardian #2 First Name Work Phone and Extension Use the "Secondary Household" feature when information needs to go to a parent/guardian/family member not living at the residence with the 4-H member.
Correspondence Preference Second Household to receive Information o Yes o No oEmail oPostal Mail City and Zip Code Emergency Contact First and Last Name Emergency Contact Phone Emergency Contact Cel Emergency Contact Email Relationship (Mom, Dad, Aunt, etc.) Are you a Teen Leader (13 and Up) who is a certified volunteer? Are you of Hispanic ethnicity? oYes oNo (please indicate both an ethnicity and race) oNative Hawai an or Pacific Islander Check al that apply: oBlack oAmerican Indian or Alaskan Native oPrefer Not to State oFarm (rural area where agricultural products are o Suburb of city more than 50,000 oTown under 10,000 and rural non-farm oCentral city more than 50,000 oTown/City 10,000 - 50.000 and its suburbs No one in my family is serving in the military oI have a parent serving in the military oI have a sibling serving in the military oAir Force oArmy oCoast Guard oDOD Civilian oMarines oNavy oActive Duty oNational Guard oReserves Effective 6/1/2016 - 5/31/2017 OK 4-H Youth Enrol ment Form 4-H Year: 2016-2017 School District/Town Home School oYes oNo Home School Group Name (as applies) REQUIRED Grade in School? T-shirt Size - state a size to the right Shooting Sports Members (only) Native American? oYes oNo If yes, Tribe Name: Youth must enrol in at least one (1) 4-H project and are limited to 10 projects. Limited enrol ment provides focus and encourages greater learning and mastery of skil s and knowledge. Through project work; youth "learn-to-learn" by independent study, project meetings and participation in workshops, tours, seminars, and camps. Project enrol ment does not limit participation in activities/events unless it is stated in the guidelines. CLOVERBUDS do not enrol in projects.
Aerospace & Rocketry Farm Machinery Flower Gardening & House Plants Recreation and Leisure Education Foods and Nutrition - Breads, Cooking/ Preparation, Preservation, Presentation, etc. Gardens - Fruits/Vegetables Safety - Home, Farm, School, Personal Goats – meat, milk and hair Science Engineering and Technology - TechXcite, GPS, UAV, Computer Science, etc… Childcare, Child Development Health & Fitness Citizenship – Government, Service Learning and Hobbies and Col ectables Shooting Sports - .22 Pistol Community Service Communication Arts - Graphics, Writing/Poetry, Horse, Donkey, Mule Shooting Sports - .22 Rifle Print, Story Tel ing, Filmmaking, Photography Companion Animals – Dog, Cat, Pocket Pets, Industrial Arts - woodworking, welding, Shooting Sports - Air Pistol Guinea Pigs, Birds, Fish, Reptiles, Other construction, etc. Consumer Education International/Cultural Education - exchange Shooting Sports - Air Rifle programs, service abroad, education abroad Shooting Sports - Archery Design and Construction - Apparel and Sewing Shooting Sports – Hunting and Wildlife Design and Construction - Hobbies and Textiles: Meats Shooting Sports-Muzzle Loader Quilting, Knitting, Embroidery, Crochet, Fabric art, Meteorology - Weather and Climate Crafts and Sewing Design and Construction - Interiors, Personal Natural Resources - Wildlife and Fisheries, Game Shooting Sports – Shotgun Living Space and Sewing Birds, Forestry, Geology, Range Electricity & Electronics Ornamental Horticulture & Landscaping Shooting Sports – Western Heritage Energy - wind, electric, hydro, solar, gas, oil, coal, Outdoor Education - Camping, Recreation, High Smal Engines Adventure, Hiking, etc. Entomology and Bees Performing Arts: Dance, Drama, Theater, Clowning, Mime, Music, etc. Entrepreneurship Personal Development Environmental Stewardship - Recycling, Tractor and Machinery Safety Composting, Water Conservation, etc. oPlant and Soil Sciences Expressive Arts: Visual Arts, Drawing, Painting, Sculpture, Crafts, Leather, etc. Public Speaking Transfering 4-H Membership? If you are new to this county and enrol ed in another OK county or state, please provide the information below and we wil transfer your membership to this county. OK County transfering enrol ment from State and county transferring enrol ment form: Effective 6/1/2016 - 5/31/2017 Youth Participant Authorizations Al boxes must be answered Code of Conduct – We have read the Code of Conduct on page 7 and understand that failure to abide by published and implied policies and regulations, including Code of Conduct, governing a 4-H program may result in loss of membership privileges. Electronic Communication w/Youth - I give permission for my student/child to receive direct email/social media/text communications from 4-H/OCES staff/volunteers for educational/programming purposes. I understand that I have a right to request a copy and receive the same information my child does. I give my child permission to communicate with educator(s)/volunteers/leaders via same said means. I understand I can withdraw permission for my child to participate at any time by giving written notice to the staff member responsible. Complete guidelines may be found in 4-H Membership Guidelines . Informed Consent, Voluntary Waiver, and Release - We have read the Liability Release on page 8 and have been informed of the University's and 4-H Youth Development's position on Liability and Assumption of Risks. Medical Release and Prescription Medication - YOUTH MEDICAL INFORMATION - Oklahoma State University requests the use of 4-H Youth Participation Form 1, pages 1 and 2 in case of emergency, we need accurate information to provide and/or seek appropriate treatment for Participant. You are accountable for providing an accurate medical history. If Participant has any medical issue that is not requested on the form, but which you think is important, please include that information. If you are uncertain about any pre-existing medical conditions, it is your responsibility to consult with your own o I agree that I am aware of and physician prior to participation in a Program. As a participant, parent, or guardian it is your understand the position of OSU and 4-H responsibility to disclose relevant information that may result in harm to Participant and/or others Youth Development in the care and during this Program. By signing this form, I represent and warrant that I have/wil provided al treatment of my child. materials and important information to Oklahoma State University pertaining to my Participant's medical, mental and physical condition and that it is accurate and complete. I agree to notify the 4-H program and or Oklahoma State University of any changes in the mental, physical or medical condition of the Participant prior to any scheduled Program.
By revealing or disclosing the medical information it wil not be used by Oklahoma State University Families are encouraged to complete the personnel or employees to determine Participant's ability to participate safely in activities. I attached portion of the Youth understand that, if Participant chooses to participate in activities, he/she does so voluntarily and of Participation form (Health) pages 5-6 as his/her own accord and the final decision regarding participation is solely the responsibility of myself part of the enrol ment process, but it is REQUIRED and Participant. Final determination about whether to participate is the responsibility of you and not required. If the child is on a your physician. This information wil be kept in strict confidence and wil only be shared with your prescription drug, the Prescription Form 2 (can be obtained from the Extension In cases where medical attention is necessary, parent/guardian wil be contacted for approval when Office or downloaded at possible; however, in the event of an emergency the 4-H staff wil seek medical care for any child in their care. Oklahoma State University does not offer any form of insurance for participant while activities/forms). It wil be the family's participating in Programs. Ful medical expense wil be the responsibility of parent or guardian. To see responsibility to update the information al Medical Form go to http://4h.okstate.edu/events-and-activities/forms. on the form as medical conditions, treatments or prescriptions change during Publicity Release - We give permission for use of name and/or picture for print/photo/video/electronic media use (including but not limited to local newspaper, social media, etc.) of the member to appear for any wide variety of formats and media for marketing, promotional or educational purposes. Complete guidelines may be found in 4-H Membership Guidelines . Survey and Evaluation Release - We give permission for the member to participate in and/or complete surveys and evaluations that wil be used to determine program effectiveness or to promote nWe understand that participation in surveys and evaluations is voluntary and that the member may choose to not participate without any impact on his or her ability to participate in the program. nWe understand that the member wil be asked for his or her verbal assent before completing a survey or evaluation. As a family we have read and discussed the Code of Conduct (pg 7), Informed Consent/Waiver (pg 8) and the various Authorizations. As a parent/guardian my signatures indicates I agree to help this member in the projects in which he/she has emrol ed. The Youth's signature indicates they wil fol ow the code of conduct and other rules associated with enrol ment.
4-H Member SignatureParent/Guardian Signature Effective 6/1/2016 - 5/31/2017 Oklahoma 4-H Youth Development

Oklahoma 4-H Youth Development Youth Participation Form PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. THIS IS A LEGALLY BINDING DOCUMENT. THIS SIGNED FORM MUST BE SUBMITTED BY A PARENT/LEGAL GUARDIAN BEFORE ANY CHILD IS ALLOWED TO PARTICIPATE IN THE REFERENCED PROGRAM/CAMP/TRIP/EVENT SPONSORED BY 4-H Program/Camp/Trip/Event Name: Date(s): Location: PARTICIPANT INFORMATION Name of Participant: Address: Gender:  M  F PARENT/GUARDIAN INFORMATION Parent/Legal Guardian Name: Address: EMERGENCY CONTACT INFORMATION Name/Relationship: Name/Relationship: MEDICAL INFORMATION - Oklahoma State University requests the information below so that in case of emergency, we have accurate information to provide and/or seek appropriate treatment for Participant. You are accountable for providing an accurate medical history. If Participant has any medical issue that is not requested below, but which you think is important, please include that information. If you are uncertain about any pre-existing medical conditions, it is your responsibility to consult with your own physician prior to participating in this Program. As a participant, parent, or guardian it is your responsibility to disclose relevant information that may result in harm to Participant and/or others during this Program. By signing this form, I represent and warrant that I have provided al materials and important information to Oklahoma State University pertaining to my Participant's medical, mental and physical condition and that it is accurate and complete. I agree to notify the 4-H program and or Oklahoma State University of any changes in the mental, physical or medical condition of the Participant prior to any scheduled Program. By revealing or disclosing the medical information in this document it wil not be used by Oklahoma State University personnel or employees to determine Participant's ability to participate safely in activities. I understand that, if Participant chooses to participate in activities, he/she does so voluntarily and of his/her own accord and the final decision regarding participation is solely the responsibility of myself and Participant. Final determination about whether to participate is the responsibility of you and your physician. This information wil be kept in strict confidence and wil only be shared with your permission. In cases where medical attention is necessary, parents wil be contacted for approval when possible; however, in the event of an emergency the 4-H staff wil seek medical care for any child in their care. Oklahoma State University does not offer any form of insurance for participant while participating in Programs. Ful medical expense wil be the responsibility of parent or guardian. Physician's Name: Date of most recent tetanus toxoid immunization: Oklahoma 4-H Youth Development Do you have health/accident insurance? (circle one): INCLUDE INFORMATION BELOW Insurance Company Name: Address: Policy/Group# Circle appropriate response and explain as appropriate. Use IF yes, identify and/or explain: additional paper if needed. Does Participant have any limiting medical conditions that you or your doctor feel would limit participation in normal 4-H projects or Is Participant currently taking medication that may interfere with ability to safely participate in 4-H Program? Does Participant have a history of al ergies or reactions to medications, insect stings, or plants? Does Participant have a history of food al ergies? Does Participant have a history of, or currently suffer from medical condition(s) with which we need to be aware? AUTHORIZATION FOR OVER-THE-COUNTER MEDICATION General y 4-H staff wil only have minor first aid supplies at overnight events and wil avoid dispensing medications; however, at times a child may become il while on an extended event or out of county trip and unless we have parental authorization, we cannot administer ANY medications. Below is a list of common OTC medication. By checking, I authorize that the fol owing medications may be given to Participant if the need arises. I shal indemnify and hold harmless the Program Staff, Oklahoma State University, its Board of Regents, Administration, Faculty, Staff, Student Leaders, and al other officers, directors, employees and agents against any claims that may arise relating to my child being administered the below indicated over- the-counter medications. Category 1 - May be administered without phone approval Category 2 - May be administered without phone approval, when possible wil be discussed with parents first.  Bug repel ent  Kaopectate or Imodium for diarrhea as directed.  Ointments for minor wound care or first aid as directed.  Milk of Magnesia, Pepto-Bismol or Mylanta for upset (Antiseptic, anti-itch, anti-sting, antibiotic, sunburn) stomach or nausea as directed.  Tylenol/Acetaminophen as directed.  Rolaids or Tums for acid reflux, heartburn or indigestion as  Ibuprofen as directed.  Throat lozenges and or spray as directed for sore throat.  Benadryl for swel ing, hives, al ergic reaction, as directed.  Hydrocortisone ointment as directed for mild skin irritations,  Actifed or Sudafed as directed for nasal congestion or al ergy poison ivy, and insect bites. relief per instructions.  Medicated powder for skin irritation as directed.  Visine or other eye drops for minor eye irritation.  Calamine lotion for bug bites and poison ivy.  Swimmer's ear drops as directed.  Medicated lip ointment for dry, chapped lips, lip blisters or  Robitussin or other cough syrup as directed. canker sores as directed.  Other (list any other approved over-the counter drugs)  Other (list any other approved over-the counter drugs) Prescription Medication Wil Participant need to take prescription medication while at the event or program? If yes, FORM #2 MUST BE COMPLETED AND ATTACHED TO THIS FORM Oklahoma 4-H Youth Development CODE OF CONDUCT - Rules and Disciplinary Procedures – keep pages 7-8 for your records Rules Participants and Parents Need to Know: In seeking uniformity in the conduct expected at each county, district, state, national, and international 4-H event, the fol owing guidelines have been developed.  Each participant has a reasonable expectation to enjoy a positive program experience. Therefore, the misbehavior of one participant, or a group of participants, wil not be permitted to impact negatively on the program experience of others. Most programs are short in duration, so prompt action is required when problems occur.  Realizing these guidelines are not "al inclusive", the Extension Service reserves the right to make adjustments to the Code  Al rules and regulations governing an activity, event or facility use wil be discussed with educators, certified volunteers, parents and 4-H'ers prior to or at the beginning of each event.  Al 4-H'ers are under the supervision of any Extension staff or certified volunteer assigned to the event.  If the 4-H'er is found in violation of the Code of Conduct and disciplinary action is required his/her parent/guardian wil be notified immediately and the 4-H'er may be suspended from participation in county, district, state, national and international 4-H activities and/or membership revoked. As deemed necessary, the appropriate County, District or State 4-H Office wil be notified of disciplinary action.  If in the event any misconduct is deemed in violation of a law, the appropriate law enforcement agency wil be notified.  Participants dismissed from a program for disciplinary reasons wil not receive a refund on any fees paid to attend.  If a 4-H'er wishes to appeal the disciplinary action he/she must appeal in writing through their County Extension Office. Appeals must be filed within 30 days fol owing notification of punishment. As necessary, the State 4-H Leader shal appoint an appeal board, no sooner than 30 days fol owing the date of notification of the disciplinary action.  Participants are responsible for securing their belongings. Neither Oklahoma State University, nor ext. staff or certified volunteer, is responsible for lost or stolen items. Leave excess money and valuables at home. Valuables brought to the program are at participants' risk and can only be used at free or other authorized times. The fol owing actions wil be considered a serious breach in conduct. This is not an al -inclusive list of conduct violations.  Assault or Personal Harm – Inflicting physical or  Theft, Misuse or Abuse of Public or Personal Property - emotional harm on self or others. Any damages caused by neglect or misuse wil be charged  Prohibit the possession, distribution, sale or use of to the responsible party. Replacement cost wil be charged il egal drugs/substances, alcoholic beverages; any to anyone who removes or damages property. Any form of tobacco or vapor products, fireworks; and/or individual found tampering with any fire equipment (i.e. fire weapons (does not limit the use of approved sporting extinguishers, fire alarms, smoke detectors, etc.) wil be arms when and where authorized). dismissed from the Program immediately. Participants may  Sexual Misconduct - Coed visitation in the residence not interfere with any security system or tamper with locks hal s is permitted in designated common areas only in participant rooms and other areas. Al furniture must not in sleeping rooms. No boys wil be al owed in remain unchanged and kept in place. girls' rooms nor wil girls be al owed in boys' rooms,  Search of Property - If a question regarding any of the either as individuals or groups. It is recognized that above is raised, 4-H member consents to a search of circumstances may arise for justifiable exceptions to his/her room and/or personal property. Failure to comply this policy. However, in every case, permission for wil result in violation of the Code of Conduct. exceptions must be secured from chaperone in The fol owing actions wil be considered a breach in conduct. This is not an al -inclusive list of conduct violations.  Breaking curfew and/or disturbing the peace - Participants wil abide by nightly curfews and remain in there until morning.  Violating the Dress Code  Use of Abusive and Offensive Language  Bul ying and Harassment – Physical, emotional or electronic harassment/harm against self, fel ow participants or staff.  Vandalism and Pranks wil not be permitted.  Unexcused Absence from the activities of the event - Participants are to remain on the event site and attend al workshops, classes, and planned social or recreational activities for the duration of the program unless program activities require otherwise. If a participant needs to leave campus or event site for some reason, supervising ext. staff or certified volunteer must have prior written approval from the parent or guardian, and agree to grant specific permission.  Unauthorized use of Vehicles during the event - Participants are not al owed to drive or ride in personal vehicles during the dates of the program unless they receive specific permission to do so from their supervising extension staff or certified volunteer. While we understand that some participants wil drive to the event, our policy is that participants should not be driving during the event. Participants may be asked to turn their car keys in to the supervising staff or certified volunteer for the duration of the program.  Misuse of Technology - Participants must never misuse internet, social media, cel phone or any new technological devices. Oklahoma 4-H Youth Development Accessing or sending unauthorized or inappropriate content is strictly prohibited. Informed Consent, Voluntary Waiver, Release of Liability & Assumption of Risks I, the undersigned, wish for my Child (hereafter "Child") to participate in the above referenced youth program (hereafter "Program") on the date(s) and location(s) indicated above and, in consideration for my Child's participation, I hereby agree as fol ows: I acknowledge, understand and appreciate that as part of my Child's participation in the Program there are dangers, hazards and inherent risks to which my Child may be exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as wel as economic and property loss. I further realize that participating in the youth program may involve risks and dangers, both known and unknown, and have elected to al ow my Child to take part in the Program. Therefore I, on behalf of my Child, voluntarily accept and assume al risk of injury, loss of life or damage to property arising out of training, preparing, participating, and traveling to or from the Program. I, on behalf of my Child, hereby release Oklahoma 4-H, Oklahoma State University, its Board of Regents, Administration, Faculty, Staff, Student Leaders, the Program Staff, and al other officers, directors, employees, volunteers and agents (hereafter "OSU") from any and al liability as to any right of action that may accrue to my heirs or representatives for any injury to my Child or loss that my Child may suffer while training, preparing, participating and/or traveling to or from the above indicted event. This agreement is binding on my heirs and assigns. In the event of an accident or serious il ness, I hereby authorize representatives of OSU to obtain medical treatment for my Child on my behalf. I hereby hold harmless and agree to indemnify OSU from any claims, causes of action, damages and/or liabilities, arising out of or resulting from said medical treatment. I further agree to accept ful responsibility for any and al expenses, including medical expenses that may derive from any injuries to my Child that may occur during his/her participation in the Program. This RELEASE shal be governed by and construed under the laws of Oklahoma. I agree that any legal action or proceeding relating to this RELEASE, or arising out of any injury, death, damage or loss as a result of my Child's participation in any part of the Program, shal be brought only in Payne County, Oklahoma. This RELEASE contains the entire agreement between the parties to this agreement and the terms of this RELEASE are contractual and are not al inclusive. The information I have provided is disclosed accurately and truthful y. I have been given ample opportunity to read this document and I understand and agree to al of its terms and conditions. I understand that I am giving up substantial rights (including my right to sue), and acknowledge that I am signing this document freely and voluntarily, and intend by my signature to provide a complete and unconditional release of al liability to the greatest extent al owed by law. My signature on this document is intended to bind not only myself and my Child but also the successors, heirs, representatives, administrators, and assigns of myself and my Child. Family - Keep pages 7-8 for your records

Source: http://4h.okstate.edu/literature-links/lit-online/others/4henrollment/201516YouthEnrollmentFinal.pdf