Clover Kids 2020

Emmet County Clover Kids 2020
Registrations are processed in order received at the Emmet County Extension Office. Space is limited, so register today! If you have questions about this program, please call (712-362-3434) or email Sidney at the Extension Office - sidneyr1@iastate.edu Complete this form for EACH participant in your family.
Clover Kids Member Info
Child's Name
First NameLast Name
Birth Date
MonthDayYear
Grade
School
Name of School
Gender
Mailing Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Parent/Guardian Information
Mother Name
First NameLast Name
Father Name
First NameLast Name
Family Number
Area CodePhone Number
Mother Cell Number
Area CodePhone Number
Father Cell Number
Area CodePhone Number
Family E-mail
Clover Kids Location Choice
Please mark based on age of Child
Volunteer
Would you want to volunteer and help out at Clover Kids?
Ethnicity
Are you of Hispanic or Latino ethnicity?
Check all the races taht apply to you. If you selected 'Not Hispanic', you must select as least one option.
Residence
What type of residence do you live?
Emergency Information
Emergency Contact's Name
First NameLast Name
Relationship
Phone Number
Area CodePhone Number
Alt. Phone Number
Area CodePhone Number
T-Shirt Size
Transportation Release
I understand that if personally-owned vehicles are used as transportation to and from Iowa State University (ISU) 4-H Club events or activities, that the owner of the vehicle is responsible for any liability that might occur during the transportation. ISU does not provide coverage for any property damage, personal injury or liability that may occur while using personal vehicles. Vehicle owners are required to carry automobile liability insurance as required by the State of Iowa.
I am giving my permission for my child to be transported during an authorized 4-H activity or event. I give my permission for: (Choose all options that apply.)
Health Form
Health Conditions
Does your child have any medical conditions?
If no, type no /// If yes, please list all relevant health conditions
Does your child have any allergies?
If no, type no /// If yes, please list
Is your child currently on any prescribed or over-the-counter medications?
If no, type no /// if yes, please list medication
Enter your (parent/adult) name to indicate that all health condition information has been recorded above correct.
Publicity/Image/Voice Permission
The Iowa State University Extension Program normally takes photographs, video, and/or tape recording of our programs. During activities, a photograph or video/audio recording may be taken of you or your child. Unless you request otherwise, you signing your name below, will be considered permission for Iowa State University and the Clover Kids program to photograph, film, audio/video tape, record and/or televise your image and/or voice or the image and/or voice of your child for use in any publications or promotional materials, in any medium now known or developed in the future without any restrictions. If you object to ISU using your child's image or voice in this manner, please notify the program leader, and type 'NO' below.
1
Type name if you agree to the above statement/ type 'NO' if you do not agree
Behavior Expectations of the Participant
It is important to follow the directions of the Clover Kids leader(s) at all times. I understand that as a Clover Kid, I will help make the activity safe for everyone and will be respectful of everyone. I also understand the danger of not following rules and directions and agree to follow them
2
Type child name above
Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
ISU Extension Clover Kids Assumption of Risk and Release of Liability
I give permission for my child to participate in the ISU Extension Clover Kids program. I understand that activities/events may involve certain risks of physical activity and possible injury and that Iowa State University and its Clover Kids program will provide each participant with reasonable care, but that ISU cannot guarantee that my child will remain free of injury. In addition, some activities including but not limited to: water activities and other sporting activities have a higher degree of risk. I nonetheless wish to have my child participate in the ISU Extension Clover Kids program and ASSUME the RISK of participating. I agree to RELEASE from LIABILITY, INDEMNIFY and HOLD HARMLESS the State of Iowa, the Board of Regents of the State of Iowa, ISU and ISU Extension and their officers, employees and agents (hereinafter the RELEASES) from any and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my child’s participation in the program. This release, however, is not intended to release the above-mentioned RELEASES from liability arising out of their sole negligence.
3
Type name above to agree to the above statement
Payment
Your registration will NOT be accepted until a payment is collected at the Emmet County Extension office. Drop off/mail payment, to the Emmet County Extension Office: 26 S 17th St Estherville, IA 51334
Should be Empty:

Emmet County Clover Kids 2020

Clover Kids Location Choice

Volunteer

Ethnicity

Residence

T-Shirt Size

Health Form

Publicity/Image/Voice Permission

Behavior Expectations of the Participant

ISU Extension Clover Kids Assumption of Risk and Release of Liability

Payment