Oklahoma 4 H Youth Enrollment Form – Fill Out and Use This PDF

OKLAHOMA 4-H YOUTH ENROLLMENT FORM	2015-2016

IMPORTANT: FIELDS MARKED WITH * ARE REQUIRED – DO NOT SKIP! FAMILY INFORMATION

*E-Mail: _____________________________________________ *Last Name: ______________________________

*Mailing Address: _______________________________________________________________________________

*City:________________________________, OKLAHOMA *Zip Code: ___________________________________

*Primary Phone: ____________________________	*Correspondence Preference: ฀ Mail ฀ E-Mail
Are you in a Military 4-H Club? ฀ Yes ฀ No
MEMBER INFORMATION
Member E-Mail: _______________________________________	*Last Name: ______________________________
Middle Name: ________________________________________	*First Name: _____________________________

Preferred Name (if different than first name):_________________________________________________________

*Birth Date (MM/DD/YYYY): ____________________________	*Gender: ฀ Female ฀ Male
Correspondence Preference: ฀ Mail ฀ E-Mail	Cell Phone: ____________________________
Do you wish to receive notices via text message? ฀ Yes ฀ No	If yes, Cell Phone Provider: __________________
*Years in 4-H: __________
PARENT 1 INFORMATION
*First & Last Name: __________________________________	Cell Phone: ________________________________

Work Phone/Extension: _______________________________

PARENT 2 INFORMATION

First & Last Name: __________________________________ Cell Phone: ________________________________

Work Phone/Extension: _______________________________

SECONDARY HOUSEHOLD INFORMATION

Does Email/Mail need to be sent to a Second Household? ฀ Yes ฀ No

Mailing Address: ________________________________________________________________________________

City:________________________________, OKLAHOMA Zip Code: _____________________________________

Second Household E-Mail: ________________________________________________________________________

EMERGENCY CONTACT

If Emergency Contact for this member is different than the parent 1 information above, please complete the information below.

*Emergency Contact Name: ___________________________________ *Phone Number: _____________________

Cell Phone Number: _________________________________ E-Mail: ______________________________________

*Emergency Contact Relationship (Mom, Dad, Aunt, etc.): _______________________________________________

VOLUNTEER - * Are you a certified 4-H Volunteer? (Teen Leader-13 and up) ฀ Yes ฀ No

Effective 6/1/2015

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Oklahoma 4-H Youth Development

	* Youth Participant Authorizations		All boxes must be answered
	Code of Conduct – We have read the Code of Conduct on page 5 and understand that failure to			Agree 
	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		Consent		Decline
	educational/programming purposes. I understand that I have a right to request a copy and
			Given		communication
	receive the same information my child does. I give my child permission to communicate with
					directly w/youth
	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
	6 a d ha e ee i for	ed of the U i ersit ’s a d 4-H Youth Developments position on Liability		Agree 
	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		I understand the position of OSU
			and 4-H Youth Development in
	responsibility to consult with your own physician prior to participation in a Program. As a
			the care and treatment of my
	participant, parent, or guardian it is your responsibility to disclose relevant information that may
					child.
	result in harm to Participant and/or others during this Program. By signing this form, I represent
	and warrant that I have/will provided all materials and important information to Oklahoma State			Check one
	U i ersit pertai i g to	Parti ipa t’s edi al, e tal a d ph si al o ditio a d that it is
			 Medical Form(s) will be
	accurate and complete. I agree to notify the 4-H program and or Oklahoma State University of
			completed as needed
	any changes in the mental, physical or medical condition of the Participant prior to any scheduled
			 Medical form to be filled
	Program.
	By revealing or disclosing the medical information it will not be used by Oklahoma State		out by family and can be
			uploaded and stored
	University personnel or employees to deter i e Parti ipa t’s a ilit to parti ipate safel i
			electronically to be used
	activities. I understand that, if Participant chooses to participate in activities, he/she does so		from Sept 1-Aug 31 each
	voluntarily and of his/her own accord and the final decision regarding participation is solely the		year
	responsibility of myself and Participant. Final determination about whether to participate is the		 Medical form to be filled
	responsibility of you and your physician. This information will be kept in strict confidence and		out by family and kept on
	will only be shared with your permission.		file in the Extension Office.
	In cases where medical attention is necessary, parent/guardian will be contacted for approval		The form is only valid Sept
			1- Aug 31 each year.
	when possible; however, in the event of an emergency the 4-H staff will 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. Full medical expense will be the responsibility of parent or
	guardian. To see the Medical Form in its entirety go to http://4h.okstate.edu/events-and-
	activities/forms.
	Publicity Release - We give permission for use of name and/or picture for				Decline – do not
	print/photo/video/electronic media use (including but not limited to local newspaper, social		Consent		use the hild’s
	media, etc.) of the member to appear for any wide variety of formats and media for marketing,		Given		name and/or
					photo for any
	promotional or educational purposes. Complete guidelines may be found in 4-H Membership
					publicity.
	Guidelines.
					
	Survey and Evaluation Release - We give permission for the member to participate in and/or
	complete surveys and evaluations that will be used to determine program effectiveness or to
	promote the program.		Consent
	∙ We understand that participation in surveys and evaluations is voluntary and that the member				Decline
			Given
					participation
	may choose to not participate without any impact on his or her ability to participate in the
					
	program.
	∙ We understand that the member will be asked for his or her verbal assent before completing a
	survey or evaluation.
		Be sure to sign the next page to complete the Authorization Agreement
	Effective 6/22/2015				Page 3 of 6

Oklahoma 4-H Youth Development

Our signature indicates that:

We have read this entire enrollment package and agree to help this member in the projects in which he/she has enrolled.

4-H Member Signature________________________________________________________________	Date ________________
Parent/Guardian Signature____________________________________________________________	Date ________________

TRANSFERRING MEMBERSHIP FROM ANOTHER STATE OR COUNTY:

If you are new to this county and were enrolled in 4-H in another county in Oklahoma or another state, please provide the information below and we will transfer your membership to this county. If you have never been enrolled as a 4-H member before or there was a lapse in membership of a year or more, this information is not needed.

Oklahoma County transferring enrollment from: __________________________________________________

OR

State and county transferring enrollment from: ___________________________________________________

Effective 6/22/2015

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Oklahoma 4-H Youth Development

CODE OF CONDUCT - Rules and Disciplinary Procedures

Rules Participants and Parents Need to Know:

I.In seeking uniformity in the conduct expected at each county, district, state, national, and international 4-H event, the following 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, will 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.

∙ Realizi g these guideli es are ot all i lusi e , the E te sio “er i e reser es the right to ake adjust e ts to poli ies.

∙All rules and regulations governing an activity, event or facility use will be discussed with educators, certified volunteers, parents and 4-H'ers prior to or at the beginning of each event.

∙All 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 will be notified immediately and the 4-H'er may be suspended from participation in district, state, national and international 4-H activities and/or membership revoked. As deemed necessary, the appropriate County, District or State 4-H Office will be notified of disciplinary action.

∙If in the event any the misconduct is deemed in violation of a law, the appropriate law enforcement agency will be notified.

∙Participants dismissed from a program for disciplinary reasons will 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 following notification of punishment. As necessary, the State 4-H Leader shall appoint an appeal board, no sooner than 30 days following 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.

II. The following actions will be considered a serious breach in conduct. This is not an all-inclusive list of conduct violations.

∙Assault or Personal Harm – Inflicting physical or emotional harm on self or others.

∙Prohibit the possession, distribution, sale or use of illegal drugs/substances, alcoholic beverages; any form of tobacco or vapor products, fireworks; and/or weapons (does not limit the use of approved sporting arms when and where authorized).

∙Sexual Misconduct - Coed visitation in the residence halls is permitted in designated common areas only not in sleeping rooms.

No boys will be allo ed i girls’ roo s or ill girls e allo ed i o s' roo s, either as i di iduals or groups. It is re og ized that circumstances may arise for justifiable exceptions to this rule. However, in every case, permission for exceptions must be secured from chaperone in advance.

∙Theft, Misuse or Abuse of Public or Personal Property - Any damages caused by neglect or misuse will be charged to the responsible party. Replacement cost will be charged to anyone who removes or damages property. Any individual found tampering with any fire equipment (i.e. fire extinguishers, fire alarms, smoke detectors, etc.) will be dismissed from the Program immediately. Participants may not interfere with any security system or tamper with locks in participant rooms and other areas. All furniture must remain unchanged and kept in place.

∙Search of Property - If a question regarding any of the above is raised, 4-H member consents to a search of his/her room and/or personal property. Failure to comply will result in violation of the Code of Conduct.

III.The following actions will be considered a breach in conduct. This is not an all-inclusive list of conduct violations.

∙Breaking curfew and/or disturbing the peace - Participants will abide by nightly curfews and remain in there until morning.

∙Violating the Dress Code

∙Use of Abusive and Offensive Language

∙Bullying and Harassment – Physical, emotional or electronic harassment/harm against self, fellow participants or staff.

∙Vandalism and Pranks will not be permitted.

∙Unexcused Absence from the activities of the event - Participants are to remain on the event site and attend all 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 allowed 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 will drive to the event, our rule 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, cell phone or any new technological devices. Accessing or sending unauthorized or inappropriate content is strictly prohibited.

Effective 6/22/2015

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Oklahoma 4-H Youth Development

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 follows:

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 well 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 allow my Child to take part in the Program. Therefore I, on behalf of my Child, voluntarily accept and assume all 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 all other officers, directors, employees, volunteers and agents (hereafter OSU ) from any and all 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 illness, 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 full responsibility for any and all 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 shall 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, shall 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 all inclusive. The information I have provided is disclosed accurately and truthfully. I have been given ample opportunity to read this document and I understand and agree to all 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 all liability to the greatest extent allowed 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.

Effective 6/22/2015

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