Florida 4-h participation form

Florida 4-H Participation Form for Youth and Adults
Directions: This form, along with a 4-H Youth Enrollment Form, must be completed by a parent or legal guardian in order for a youth to
participate in the Florida 4-H Program. All items must be completed. Even if the response is not applicable – indicate by using N/A. Failure to
complete this form in its entirety will result in the person being ineligible to participate in 4-H activities. Adult participants must also complete
this form to volunteer with and/or participate in Florida 4-H.
HEALTH HISTORY
Does the participant have, or at any time had, any of the following? Check “Yes” or “No” to each item. Please explain any “Yes” answers (noting the # of the item) in the space below or on an additional sheet of paper if necessary. Reporting conditions will not prevent a person from attending and will be kept confidential. Please explain “Yes” answers and provide information on recent medical issues (including injuries and surgeries), allergic reactions, special dietary regulations, present medications, any specific activities to be restricted and other comments. The following over-the-counter medications may be administered Please contact me for permission to administer ANY
Disabilities: If the member or adult requires accommodations for a disability to participate in 4-H Programs, please provide information about
the disability.
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Medical Consent
First Aid Consent: I give UF/IFAS Extension 4-H my consent and permission to render general first aid treatment to my child or myself for
any injuries or illnesses occurring during any Florida 4-H activity. I understand that if a medical emergency arises, Florida 4-H will contact
emergency medical personnel [911] for assistance.
Medication Consent: I authorize UF/IFAS Extension 4-H to administer medication (over the counter and/or prescribed) to my child as
specified in the physician’s written instructions or instructions on packaging. I understand that if my child needs medication to be
administered while attending a Florida 4-H activity, I MUST complete the Florida 4-H Medication Form in addition to signing this
consent.
I understand and agree to the Medical Consent. I am a Parent/Guardian or Adult Participant. *


* Consent is required to participate in Florida 4-H.
Florida 4-H Participation Form for Youth and Adults: Authorizations
Florida 4-H Code of Conduct for Youth and Adults
As a participant in 4-H at the local, state, or national level, I have the responsibility of representing the UF/IFAS Extension 4-H Youth Development Program to the
public. Therefore, I am expected to conduct myself in a manner that will bring honor to me, my family, my community, and 4-H. To do that, I must abide by the
following rules:
(1) Obey local, state, and federal laws. Follow county, district, state and/or national 4-H policies. Abide by any special rules for a 4-H event or activity.
(2) Speak and act in a responsible, courteous, and respectful way. Harassment, threats or bullying of any type is prohibited.
(3) Act responsibly to maintain a safe environment for all participants. Acting in a manner that could endanger the health, safety or welfare of yourself or others is
prohibited. Report threats to the well-being of any participant immediately to the adult in charge.
(4) Possession or use of tobacco, alcohol, or illegal drugs is prohibited. Possession or use of approved medications by youth during a 4-H function must be reported
to the adult in charge and must not be accessible to other participants.
(5) Possession or use of weapons or other dangerous objects is prohibited, except when required as part of an approved educational program. Weapons are defined
to include, but are not limited to, guns, knives and incendiary or explosive devices of any kind.
(6) Respect all property, facilities, equipment, and vehicles. I will be responsible for any damage or other consequences resulting from my behavior.
(7) Participate fully in 4-H functions. Be in the assigned program areas (example—dorms, cabins, programs, etc.) on time. If I am unable to attend or participate, I
will tell the adult in charge. Help others have a pleasant experience by making every attempt to include all participants in activities.
(8) Dress appropriately for each 4-H function.
(9) Use of any mobile electronic device during a scheduled 4-H activity is prohibited unless activity-specific rules otherwise allow. When permitted, they should be
used only in a manner that is consistent with the approved activity and not discourteous or disruptive.
(10) The belongings of youth participants, including but not limited to bags, purses, computers, other electronic devices, lockers and vehicles, are subject to search
and seizure by 4-H faculty/staff, and in some instances a volunteer designee, upon reasonable suspicion that a prohibited and/or illegally possessed substance or
object is contained within that area. (If an adult is suspected, this will be handled by law enforcement.)
Youth or Adult Member Agreement: Yes
I have read the Florida 4-H Code of Conduct above and agree to abide by it in its entirety. I
realize my failure to do so could result in a loss of privileges during a 4-H event and in the future; including but not limited to suspension or termination of
4-H membership or volunteer service.**
Parent/Guardian Agreement: Yes
I understand and agree to the Florida 4-H Code of Conduct above. **
General Release: In consideration for my and/or my child’s participation in Florida 4-H, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE
Florida 4-H, the Florida 4-H Foundation, UF IFAS Extension, the University of Florida, the University of Florida Board of Trustees, and their respective
employees, agents, representatives and volunteers (hereinafter referred to as “RELEASEES”) from any and all liability, claims, demands, actions and causes of action
whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by my child, or to any property belonging to me,
WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES or otherwise, while participating in a Florida 4-H activity or while in, on or upon the premises
where a Florida 4-H activity is being conducted.
I am fully aware of the risks and potential hazards connected with participating in Florida 4-H activities and programs and I hereby elect to voluntarily participate
and engage in such activities knowing that these activities may be hazardous to me, my child and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY
FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, that may be sustained by myself, my child, or any loss or damage to property owned by
me, as a result of engaging in such activities, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise.
Yes
I understand and agree to the General Release. I am a Parent/Guardian or Adult Participant. **
Publicity Release: I authorize UF/IFAS Extension and the Florida 4-H Foundation or their assignees to record and photograph my image and/or voice (or that of
my child if under 18) for use in research, educational and promotional programs. I also recognize that these audio, video and image recordings are the property of
UF IFAS Extension and the Florida 4-H Club Foundation.
I authorize use of my—or my child’s individual image or voice. I am a Parent/Guardian or Adult Participant ***

Survey & Evaluation Release: I hereby establish my willingness to participate as an adult (i.e. 4-H leader, other volunteer, parent/ guardian, site manager, etc.)
and give permission for my child (under 18 years of age) to complete surveys and evaluations that will be used to determine program effectiveness or to promote
the program. I understand that participation in surveys and evaluations is voluntary and that my child and I may choose not to participate and may withdraw from
surveys and evaluations without impact on my or my child’s eligibility to participate in the 4-H program. I understand that my child or I may be asked for consent
before completing a survey or an evaluation.
I am willing to participate—or give permission for my child to participate—in any program evaluation. I am a Parent/Guardian or
Adult Participant ***


Transportation Policy: I understand that all volunteers and/or parents who transport Florida 4-H participants as a part of any 4-H activity are required to be 18
years or older, possess a valid driver’s license with a safe driving record and automobile insurance, and otherwise comply with state and local laws. Additionally,
Florida 4-H requires that drivers utilize a transport vehicle that is in good repair and working order.
I understand that transportation to and from many Florida 4-H activities, not a part of the activity, is the responsibility of the participant and his/her family. Florida
4-H has no ownership or control over any privately owned vehicles and relies on the drivers’ compliance to 4-H policies and procedures.

Yes
I understand and agree to the Transportation Policy. I am a Parent/Guardian or Adult Participant. **
**Consent is required. Marking “No” for the Code of Conduct, General Release and Transportation Policy will prevent the individual from participating in Florida 4-H. ***Consent is not required to participate in Florida 4-H.
Member Signature: ______________________________________________________Date: _______________________
Parent/Guardian Signature: ______________________________________________ Date: _______________________

Source: http://florida4h.org/participation-form.pdf