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MARYLAND 4-H TEEN
FOCUS LEARNING AND
LEADERSHIP
2013 State 4-H Teen Focus
One World, One 4-H, One Dream…To Make the Best
Better June 25-27, 2013
Maryland State 4-H Teen Leadership Conference will be held at the beautiful University of College Park Campus June 2527, 2013. This is the premier, statewide annual 4-H event for teens. The mission of Teen Focus is to provide educational
experiences on a campus setting that help participants to develop life and leadership skills. This is a great opportunity
for youth to make decisions about their future educational and professional endeavors.
In 2013 we will be teaming up with Future Farmers of America (FFA) to offer a fabulous event. This collaboration provided
both organizations the ability to increase their capacity to offer premier youth development programs. One example is the
keynote speaker, Ricky Kalmon a famous motivational speaker. Many of you may recognize him from the Disney show
Snapp. In addition, he has made numerous special guest appearances on Fox, FX, E, and Comedy Central. Kalmon’s
uniqueness comes from the way he combines music, audience participation, and comedy to create an unforgettable
show which is unmatched by anyone. It’s a show that will keep you on the edge of your seat and take you on a Vacation
of the Mind! We know it will be an awesome memorable experience for all in attendance.
FFA and 4-H have an amazing line up of workshops for the conference. Combining the groups has allowed us to bring in
outside presenters from a variety of organizations. Our extraordinary line up of classes for Teen Focus range from CSIBarnyard, Zumba, Campus Tours, Health Rocks! Youth Mini-Grants, Livestock, Healthy Lifestyles, Community
Leadership, to Entrepreneurship. It is definitely a line up everyone will love. 4-H’ers and FFA youth will attend classes
together. This year, instead of signing up for classes in advance, youth will receive an on-line link where they can register
on-line. By combining the two groups, we now expect more than 400 teens from all across the state of Maryland in
attendance.
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The Goals for 4-H Teen Focus are to:
•
•
•
•
•
•
•
•
provide a high-quality educational experience for 4-H youth ages 14-18 and adults that work with them
promote 4-H as a major statewide educational youth program
provide educational, recreational and social experiences for teens
that would not normally be available at a county or district level
provide educational experiences through seminars, workshops,
and service learning that will enhance life skill development and
support 4-H project work
provide first hand experiences on college campus exposing participants to
“college life”
provide opportunities for teens and adults to specifically develop
leadership related life skills
promote an understanding of the value of diversity among
Teen Focus participants
enhance each delegate’s sense of personal and social responsibility through an environment that fosters
independence, accountability, decision-making and time management
Now that you know a little more about Teen Focus, I’d like to invite you to join us at this wonderful event! You will
have an exciting adventure as you explore first-hand the life of a college student. Let the 4-H program help guide
you into your voyage to adulthood and give you a backdoor look into University of Maryland, College Park. A solid
Institute founded in 1856, College Park is consistently rated as one of the best institutions in the world.
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2013 State 4-H Teen Focus
One World, One 4-H, One
Dream…To Make the Best
Better
June 25-27, 2013
Schedule of Events
Tuesday,
Noon
1:00
4:00
5:00
6:45
8:00
9:00
10:00
10:40
12:00
June 25th:
Teen Council Members Arrive
Check-in for all other Participants
Get to know Games lead by Teen
Council
Dining Hall
Welcome Meeting- Set
Expectations Introductions
Hypnotist –Ricky Kalmon
Return to Dorms
Small Group Meetings
Whole Group Meetings Team
Challenges
Midnight Lights out
Wednesday, June 26th:
7:00
Breakfast
8:30
Gathering Assembly
9:30
WORKSHOPS
11:30
Lunch
1:30
WORKSHOPS
3:30
Break
3:45
WORKSHOPS
5:00
Dinner
6:30
Small Group Meetings
8:00
Dance
10:00
Whole Group Meetings
Team Challenges
12:00
Lights out
Thursday, June 27th
7:00
Breakfast
8:00
Whole Group Meetings Skits
and Challenges
9:00
WORKSHOPS
10:00
Committee Meetings
11:00
Capnote Speaker/Lunch
1:00
Clean Up Pack Up
2:00
Participant Release
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2013 State 4-H Teen Focus
One World, One 4-H, One Dream…To Make the Best Better
June 25-27, 2013
REGISTRATION FORM
 Registration must be sent to your local 4-H office before June 10, 2013 for appropriate signatures. Full payment and signed forms
must accompany the registration form!
 Incomplete registrations or registrations without the required forms will not be accepted.
 No refunds for cancellations.
Please print legibly or type from your computer-Thank you!
1
County/City:
2
Last Name:
First Name:
3
Date of Birth (mm/dd/yyyy):
Age:
Male or Female
4
Address:
City:
State:
Zip:
Phone:
5
Daytime:
Evening:
Cell:
6
Email:
7
Check or Circle One:
Teen
State 4-H Teen Council Representative
8
Dietary concerns or restrictions? Explain:
9
Roommate Preference:
10
Tee Shirt Size – Check or Circle One:
S
M
L
XL
XXL
Other
PHOTO RELEASE:
I give permission to the College of Agriculture and Natural Resources, University of Maryland Extension, to use and publish my photograph for
educational and promotional purposes without compensation.
Name:
Phone #:
Signature:
If Minor, Signature of Parent or Guardian:
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or parental status, or national origin.
5|Page
Check or Circle One:
12
Teen $225.00
TEEN COUNCIL: $50.00. Only teen council members who have voting rights are eligible to receive
this reduced rate. Dr. Dennis will be sending each eligible Teen Council Member a notification of their eligibility for this discounted rate. Please
include your letter with this registration to verify your discounted rate.
If you will be receiving a scholarship please provide payment information:
Check or Circle One:
14
Scholarship:
Yes
No
Amount:
Who is providing your scholarship:
15
Payment Information: Make Check Payable to: Maryland 4-H Foundation
Amount Due: $_
16
Check or Circle One:
FRS#
Cash
Check - Check #
VISA
MasterCard
17
Card Number:
Name on Card:
Expiration Date:
18
Signature of Account Holder:
Last Three Numbers on Back of Credit Card:
Participant Signature:
Parent/Guardian Signature:
Contact: Dr. Lisa M Dennis, ldennis@umd.edu , Phone: 410-603-0000 or 410-651-8330
Please send all completed forms to:
Teen Focus
Att: Mel Johnson
University of Maryland Extension 4-H Youth Development
The Maryland 4-H Center
8020 Greenmead Drive
College Park, MD 20740-4000
mjohns42@umd.edu 301 314-9070 | Fax 301 314-7146
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or parental status, or national origin.
6|Page
A goal of the Maryland 4-H program is to provide opportunities for children and youth to build character. Maryland 4-H supports the CHARACTER COUNTS!SM six
pillars of character: TRUSTWORTHINESS, RESPECT, RESPONSIBILITY, FAIRNESS, CARING AND CITIZENSHIP. In order to ensure that Maryland 4-H
programs provide positive environments for all individuals to learn and grow, 4-H participants agree to abide by these expectations of behavior:
(CHARACTER COUNTS! Is a service mark of the CHARACTER COUNTS! Coalition, a project of the Josephson Institute of Ethics.)
I will be trustworthy. I will be worthy of trust, honor and confidence. I will be a model of integrity by doing the right thing even when the cost I high. I will be honest
in all my activities. I will keep my commitments by attending all sessions of the planned event. If I am not feeling well or have a schedule conflict, I will inform my
chaperon or a person in charge. I will be in the assigned area (e.g., club meeting room, building, dorm) at all times. Maryland 4-H does not permit dishonesty by
lying, cheating, deception or omission.
I will be respectful. I will show respect, courtesy, and consideration to everyone, including myself, other program participants and those in authority. I will act and
speak respectfully. I will treat program areas, lodging areas, and transportation vehicles with respect. I will not use vulgar or abusive language or cause physical
harm. I will appreciate diversity in skill, gender, ethnicity and ability. Maryland 4-H does not tolerate statements or acts of discrimination or prejudice.
I will be responsible. I will be responsible, accountable and self-disciplined in the pursuit of excellence. I will live up to high expectations so I can be proud of my
work and conduct. I will be on time to all program events. I will be accountable by accepting responsibility for my choices and actions. I will abide by the established
program curfew. I will be responsible for any damage, theft or misconduct in which I participate.
I will be fair. I will be just, fair and open. I will participate in events fairly by following the rules, not taking advantage of others and not asking for special exceptions.
I will be caring. I will be caring in my relationships with others. I will be kind and show compassion for others. I will treat others the way I want to be treated. I will
show appreciation for the efforts of others. I will help members in my group to have a good experience by striving to include all participants.
I will be a good citizen. I will be a contributing and law-abiding citizen. I will be respectful to the environment and contribute to the greater good. I will not use any
illegal substances such as tobacco, alcohol and drugs.
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or parental status, or national origin.
7|Page
Maryland 4-H Disciplinary Policy and Procedures
I.
II.
III.
Maryland 4-H expects youth participating in programs to behave in an acceptable manner and in accordance with the Maryland 4-H Behavioral Expectations outlined on the reverse
side of this document. 4-H participants, who engage in unacceptable conduct, including the following behaviors, are subject to discipline.
• Possession, use, or distribution of alcohol and/or illegal drugs.
• Possession or use of weapons or dangerous materials.
• Possession or use of tobacco products.
• Misuse of prescription or nonprescription drugs.
• Sexual activity.
• Lying, cheating, and misrepresenting project work or other unethical practices.
• Unauthorized absence from program site.
• Physical, verbal, emotional, or mental abuse of or threats toward another person.
• Theft, destruction, or abuse of property.
A participant in a 4-H program who engages in conduct (including the above behaviors) that, in the discretion of the extension faculty, staff or UME volunteer in charge, may jeopardize
the health or safety of the participant or others, or the integrity of 4-H, will be dismissed immediately from the program (meeting, activity, event, trip, camp, etc.). The participant’s
parent or guardian will be responsible for providing transportation home for a child if dismissed.
Following a program, a participant and his/her parent or guardian will be notified in writing of the nature of any unacceptable conduct for which sanctions (up to and including
suspension from one or more 4-H programs or dismissal from (4-H) are being considered. In such cases:
• The extension faculty or staff member with overall responsibility for the program will set up a meeting to hear the 4-H member. The 4-H member’s parent or guardian will be
permitted to be present at such time. At the discretion of UME or at the request of the 4-H participant, a committee may be appointed by UME to review the matter.
• Following the meeting, the 4-H participant and his or her parent/guardian will be notified in writing of the outcome of the meeting and any sanction(s) to be imposed.
• Sanctions may be appealed in writing within seven (7) days after receiving notice of the decision, to the County Extension Director (CED) or Area Extension Director
(AED). I
• The 4-H participant and his/her parent or guardian will be notified in writing of the decision of the AED/CED. The decision of the ADE/CED may be appealed in writing
to the State 4-H Leader within seven (7) days after receiving notice of the decision. The decision of the State 4-H Leader will be final.
“I HAVE READ THE MARYLAND 4-H BEHAVIORAL EXPECTATIONS AND THE MARYLAND 4-H DISCIPLINARY POLICY AND PROCEDURES. I AM AWARE THAT MY ACTIONS AND
DECISIONS AFFECT ME AND OTHERS AND MAY RESULT IN LOSS OF PRIVILEGES DURING 4-H PROGRAMS, AND FOR FUTURE PROGRAMS. I WILL ACCEPT THE APPROPRIATE
AND LOGICAL CONSEQUENCES OF MY ACTIONS, AS DETERMINED BY MARYLAND 4-H.”
Member Signature
_
Date
“AS THE PARENT/GUARDIAN OF
, I HAVE READ THE MARYLAND 4-H BEHAVIORAL EXPECTATIONS AND THE MARYLAND
4-H DISCIPLINARY POLICY AND PROCEDURES AND WILL SUPPORT THE INDIVIDUAL IN CHARGE IN MAINTAINING APPROPRIATE BEHAVIOR. I AGREE TO ACCEPT THE
APPROPRIATE AND LOGICAL CONSEQUESNCES OF MY CHILD’S ACTIONS AS DETERMINED BY MARYLAND 4-H.”
Parent/Guardian Signature
Date
Revised LMD 2010
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or parental status, or national origin.
UNIVERSITY OF MARYLAND EXTENSION
ADULT AND YOUTH HEALTH FORM
Youth
MEP 323
Adult
Participant’s Name
Sex
Last
Age as of Jan. 1of current year
First
Middle Initial
Nickname
Birth date
Complete Home Address
T telephone: day (
)
Telephone: evening (
)
Work Telephone (
)
Work Telephone (
)
Name of Custodial Parent/Guardian
Home Telephone (
)
Name of Non-Custodial Parent/Guardian
Home Telephone (
)
If Parent/Guardian is not available in an emergency, contact:
T telephone (
)
Relationship to Individual
Family Primary Care Physician
Telephone (
Family
)
Telephone (
Family Dentist
Health
Insurance
Policy Number
)
Carrier
Name of Insured
No Insurance Coverage
Insurer requires authorization from primary care physician prior to treatment.
Health History
Check all that apply; give approximate date of onset
Frequent Ear Infections
Seizure Disorder/Convulsions
Mononucleosis
As t h m a
German measles (Rubella)
Menstrual Cycle Started
Bed Wetting
Heart Defect/Disorder
Diabetes
Sleep Walking
C h ick e n P ox
Mumps
Urinary Tract Infection
Recent Surgery: Please explain
High Blood Pressure
Bleeding Clotting Disorders
ADD/AD HD
M e a sl es
Hepatitis
Head Injury
Please list any additional important health information or dietary restrictions.
Allergies Check all that
apply.
Hay Fever
Poison Ivy, Oak, etc.
Insect Bites
Insect Stings*
Penicillin
Sulfa
Iodine
Other allergies: Please List Below
Foods allergies: Please List Below
This individual requires immediate medical attention for treatment of allergies — please specify
*Please note if epinephrine is with adult/child
.
Immunization History
Please record month and year of basic immunizations and most recent booster doses.
Vaccines
Year of Basic Immunization
Year of Last Booster
Diphtheria
Pertussis
Tetanus
Chickenpox
Oral Polio
Injectable Polio
Measles
Mumps
Rubella
TB Test
-
Haemophiles influenza B
Most Recent:
Hepatitis B
Other
Medications
Please list ALL medications the individual routinely takes. Bring at least enough medication to last for the program’s duration. Keep medication in the original container, which identifies the name of the medication, its
dosage, and frequency of administration; the prescription number; and the physician’s name and phone number.
Prescription
Medication
Dosage
Specific Times Taken
Reason For Taking
Dosage
Specific Times Taken
Reason For Taking
Non-Prescription
Medication
Individual requires no regular medication.
I give permission to the selected UME staff or volunteer to administer the medications listed above, along with
any of the following additional medications that I have check marked, if the staff or volunteer deems it necessary.
Acetaminophen
Aspirin
Ibuprofen
Pepto Bismol
Calamine lotion
Imodium AD
Cough drops
Sunscreen
Dosages will be administered according to directions on the c o nt a ine r unless a physician directs otherwise.
Additional information, for medical staff only, may be attached in sealed e nve lo p e .
Signature of Participant or Parent/Guardian if
participant is under 18 years old
Print Name of Parent/Guardian
Date
Participation
(Program name)
This participant is allowed to participate fully in this
which may inc lude swimming, canoeing, hiking, sports, and other strenuous events/activities?
Yes
No
,
Specify restriction
Additional information for health care staff:
Signature of Participant or Parent/Guardian if
participant is under 18 years old
Print Name of Parent/Guardian
Date
AUTHORIZATION FOR PARTICIPTION AND RELEASE:
I hereby give permission for medical personnel
selected by University of Maryland Extension (UME) to provide routine health care; to order x-rays, and
routine tests; to administer medications, injections, anesthesia, surgery, and other treatment; to release
records necessary for insurance purposes; and to provide or arrange necessary related transportation for
me/my child. In the e ve nt I cannot be reached in an emergency, I hereby give permission for medical personnel selected by UME to secure and administer treatment including hospitalization for the p ar t ic ip a nt
named above. I further understand that I will be responsible for medical/hospital bills. By signing this
form, I give permission for the p ar t ic ip a nt named above to participate in all program activities except as
specified herein. This completed form may be copied for trips o ut o f camp and/or away from the p r o gr a m site.
By signing this form, I release and forever discharge, agree not to sue, and to indemnify and hold harmless
the State of Maryland, University of Maryland, and University of Maryland Extension and/or their officers,
agents, employees, faculty, staff, and volunteers from and against any and all liabilities, costs, expenses,
causes of action, claims, and/or demands in any way relating to the foregoing program activities and/or the
health, illness, injury, and/or treatment of the participant named above.
I AM 18 YEARS OLD OR OLDER AND I HAVE READ AND FULLY UNDERSTAND THIS AUTHORIZATION FOR PARTICIPTION AND TREATMENT AND RELEASE.
Signature of Participant or Parent/Guardian
if participant is under 18 years old
Print Name of Participant or Parent/Guardian
if participant is under 18 years old
Date
(Or)
Signature of Parent/Guardian of
18 year old (optional)
Print Name of Parent/Guardian of
18 year old (optional)
Date
THIS SECTION FOR OVERNIGHT RESIDENTIAL PROGRAM PARTICIPANTS ONLY.
HEALTH EXAM
To be completed by doctor
Participation
This individual is allowed to participate fully in this pr o gr a m, which may inc lude swimming, canoe- ing,
hiking, sports, and other strenuous events:
Yes
No
Specify restrict ion
Additional information for health care staff:
I have examined this individual within the past 2 years. Date Examined
Height
Weight
/
/
Blood Pressure
Currently under care of physician for
Signature of Physician
Nurse/Physician’s Assistant completing form
Print Name of Physician
Print Name of Nurse/Physician’s Assistant
Date
Date
Personal Identification Form
In an effort to provide a safe and enjoyable educational experience, we ask that you complete this
information. This information will be used in case of an emergency to help mobilize assistance and to
distribute to those providing assistance.
Participant’s Name
Telephone: (
)
Address
Recent Photograph
(Within Past Year)
Parent/Guardian Name
Emergency Contact:
Telephone: (
)
Individual’s Physical Description
Age
Sex
Hair Color
Race
Height
Eye Color
Weight
Glasses
Yes
No
Contacts
Yes
No
Facial Features/Shape
Teeth (Normal, gaps, chipped, braces, etc.)
Distinguishing Marks/Scars
Physical Condition
Mental Condition
Emotional Condition
Hobbies & Interests of Individual
Personal/Family situation that could cause concerns:
-
i,
Other habits/personality information that could be helpful
MEP 323
Issued in furtherance of Extension work, acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, University of Maryland,
P
College Park, and local governments. Cheng-i Wei, Dean and Director of University of Maryland Extension.
The University of Maryland is equal opportunity. The University’s policies, programs, and activities are in conformance with pertinent Federal and State laws and
regulations on nondiscrimination regarding race, color, religion, age, national origin, gender, sexual orientation, marital or parental status, or disability. Inquiries
regarding compliance with Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Educational Amendments; Section 504 of the Rehabilitation Act of
1973; and the Americans With Disabilities Act of 1990; or related legal requirements should be directed to the Director of Human Resources Management, Office
of the Dean, College of Agriculture and Natural Resources, Symons Hall, College Park, MD 20742.
2001
UNIVERSITY OF MARYLAND
UNIVERSITY OF MARYLAND EXTENSION
PARENTAL RELEASE AND INFORMED CONSENT FORM
PROGRAM:
Maryland 4-H Teen Focus
DATE(S):
June 25-27, 2013
My minor child, as listed below, has my permission to fully participate as a representative of the University of Maryland Extension (UME)
Maryland 4-H Youth Development Program in all activities associated with the above named program.
In connection with and consideration of my child’s participation in the Program, I, on behalf of my child and myself, my heirs, personal
representative(s) and assigns, hereby represent and agree as follows:
1.
I am aware that any program related activity can be dangerous, and I fully recognize and understand that there are risks
and hazards, both minor and serious, associated with participation in the Program and related activities, including, but
not limited to: cuts, scrapes, bruises, broken bones, muscle strains, pulls or tears, head, neck, back, eye and other bodily
injuries, heat prostration, brain damage, blindness, deafness, drowning, heart attacks, paralysis and, even, death. The
following is a description and examples of specific, significant, non-obvious dangers and risks associated with this
activity. There is potential for accidents and/or injuries arising from: (Add the activities here – see sample for suggestions)
a. transportation by public/contracted carrier or vehicle driven by a volunteer or UME staff member.
b. residing in a campus dormitory with youth and/or adults of the same gender.
c. use of campus pool and/or other recreational or campus facilities.
d. fire and/or weather or natural events.
e. educational and recreational activities held off of the campus such as field trips to Assateague and Tangier.
2.
I understand that my child is not in any way required to participate in the Program, but I want them to participate, despite
the possible dangers and despite this Release.
3.
I represent and warrant that my child has no physical, health related or other problems which would preclude or restrict
their participation in the Program or otherwise render their participation dangerous or harmful to them or others. I
further represent and warrant that my child has adequate medical, health and/or other insurance for participation.
4.
Knowing the dangers, hazards and risks associated with the Program, and with sufficient knowledge of my child’s
physical condition(s) and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage, illness
and/or injury to person or property which my child may, in any way, sustain in connection with participation in the
Program and related activities.
5.
I agree that my child must abide by all rules and regulations applicable to participation in the Program. Should my child
require emergency medical treatment or first aid as a result illness or injury associated with the Program or related
activities, I consent to such first aid and/or treatment.
6.
To the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and to indemnify and
hold harmless, the State of Maryland, the University of Maryland, University of Maryland Extension and their governing
boards, officers, agents, employees and volunteers from and against any and all liabilities, claims, demands and causes of
action of any kind on account of any loss, damage, illness or injury to person or property in any way arising out of or
relating to my child’s participation in the Program and/or related activities, whether due to the negligence, mistake or other action or
inaction of UME or any other person or entity.
7.
I do hereby consent and agree that the Maryland 4-H Youth Development Program has the right to take photographs or record
video/audio tapes of my child and to use these for educational and/or promotional materials. I further consent that my child's name
may be revealed therein or by descriptive text or community. I hereby release to the Maryland 4-H Youth Development Program all
rights to exhibit this work publicly or privately, including posting it on the Maryland 4-H Website. I waive any rights, claims or
interests I or my child may have to control the use of my child's identity or likeness in the photographs, video or audio, and agree that
any uses described herein may be made without compensation or additional consideration of me or my child.
I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ AND FULLY UNDERSTAND THIS RELEASE
AND INFORMED CONSENT FORM, AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.
Signature of Parent/Guardian Having Care and Custody of Participating Child
Name of Parent/Guardian:
Participating Child’s Name:
Date
Emergency Telephone: (
Signature:
)
Age:
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or parental status, or national origin.
Rev. - July 2000 (D. Andrews)
Updated for Extension Name and Logo Change
AMT 3/2010
UNIVERSITY OF MARYLAND
UNIVERSITY OF MARYLAND EXTENSION
OVER 18 RELEASE AND INFORMED CONSENT FORM
PROGRAM:
Maryland 4-H Teen Focus
DATE(S): June 25-27, 2013
I wish to participate as a representative of the University of Maryland Extension (UME) Maryland 4-H Youth Development
Program in all activities associated with the above named program.
In connection with and consideration of my participation in the Program, I, on behalf of myself, my heirs, personal
representative(s) and assigns, hereby represent and agree as follows:
1.
I am aware that any program related activity can be dangerous, and I fully recognize and understand that there
are risks and hazards, both minor and serious, associated with participation in the Program and related activities,
including, but not limited to: cuts, scrapes, bruises, broken bones, muscle strains, pulls or tears, head, neck,
back, eye and other bodily injuries, heat prostration, brain damage, blindness, deafness, drowning, heart attacks,
paralysis and, even, death. The following is a description and examples of specific, significant, non-obvious
dangers and risks associated with this activity. There is potential for accidents and/or injuries arising from:
a.
b.
c.
d.
e.
transportation by public/contracted carrier or vehicle driven by a volunteer or UME staff member.
residing in a campus dormitory with youth and/or adults of the same gender.
use of campus pool and/or other recreational or campus facilities.
fire and/or weather or natural events.
educational and recreational activities held off of the campus such as field trips to Assateague and Tangier Islands.
2.
I understand that I am not in any way required to participate in the Program, but I want to participate, despite
the possible dangers and despite this Release.
3.
I represent and warrant that I have no physical, health related or other problems, which would preclude or restrict
my participation in the Program or otherwise render my participation dangerous or harmful to them or others.
I further represent and warrant that I have adequate medical, health and/or other insurance for participation.
4.
Knowing the dangers, hazards and risks associated with the Program, and with sufficient knowledge of my
physical condition and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage,
illness and/or injury to person or property in any way associated with my participation in the Program and
related activities.
5.
I agree to abide by all rules and regulations applicable to participation in the Program.
6.
To the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and to
indemnify and hold harmless, the State of Maryland, the University of Maryland, University of Maryland
Extension and their governing boards, officers, agents, employees and volunteers from and against any and all
liabilities, claims, demands and causes of action of any kind on account of any loss, damage, illness or injury
to person or property in any way arising out of or relating to my participation in the Program and/or related
activities, whether due to the negligence, mistake or other action or inaction of UME or any other person or
entity.
I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ AND FULLY UNDERSTAND THIS
RELEASE AND INFORMED CONSENT FORM, AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS
SIGNIFICANCE.
Signature of Participant
Date
Printed name of Participant
Date of Birth
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or
parental status, or national origin.
Updated for Extension Name and Logo Change 3/2010 AMT 3/2010