2012-2013 Jackson County 4-H Leader Enrollment Form
Directions: Print clearly. Complete one enrollment form, list all clubs & projects. NOTE: Leaders MUST HAVE TAKEN 4-H Leader Training and pass
background criminal screening prior to enrolling. Complete the Health Form Release Statements and Adult Volunteer Code of Ethics on the back of this form.
Leader Name:
(
Please print
Last name
First name
MI
)Gender: F __ M __
(Preferred name to be called)
Mailing Address:
Oregon
Please print
Street address
City
PHONES (541)
Please print
State/Zip
(541)
(Primary):
(Cell):
Occupation (optional) _____________________________________
E-mail addresses (print clearly):
(541)
Other:
Work: (Can you be called at work? _______ )
Highest Level of Education (optional) __________
Leader
secondary email
Disabled or have serious health considerations?  Yes  No What?_______________________________________
(more detail on back)
Racial Group: (Check all that apply)  White,  Black,  American Indian,  Asian,  Hawaiian or Pacific Islander
Ethnicity:  Hispanic,  Not Hispanic;
Residence:  Farm,  Town (>10K),  Town (10K-50K),  Suburbs (>50K),  City (> 50K)
Member of active/reserve military family?  Yes  No If yes, what branch?
Want 4-H mailings?  Yes  No
Have you been in 4-H before? ?  Yes  No No. of Years in 4-H (counting this year) ____;
Year completed 4-H Leader Training _________;
or check here  I plan to take leader training this year?
.
Leader Role Codes: C = Contact Leader; PC = Project Leader; (Note: Resource Leaders do not need to be listed in particular club)
Club names. List primary club first
Leader
code
FEE
PAID
l.
2.
3.
Projects you will be leading:
years
in proj
1.
2.
3.
Return completed form and $2.00 County Insurance fee, to
OSU Extension Service, 569 Hanley Rd, Central Point,OR 97502
DEADLINE: March 15, 2013, to participate in County Fair
Years
in proj
4.
5
6
7.
Complete pg.2 on back
=======================================================================================================================
Oregon State University Extension Service offers educational programs, activities, and materials – without regard to race, color, religion, sex, sexual orientation, national origin,
age, marital status, disability, and disabled veteran or Vietnam-era veteran status – as required by Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of
1972, and Section 504 of the Rehabilitation Act of 1973. Oregon State University Extension Service is an Equal Opportunity Employer. The Extension Service offers its programs
and materials equally to all people. Reasonable accommodations will be provided to those with physical or mental disabilities in order to attend Extension programs. Please contact
the Extension office in advance to make arrangements. Agriculture, Family and Community Development, 4-H Youth, Forestry and Extension Sea grant Programs, Oregon State
University, United States of Agriculture cooperating.
For Office Use Only
Date in office: ______________
 Amount paid $2.00
 Cash
 Check #___________  Payment recorded
payable to Jackson County 4-H Leaders,
Data Entry Date___________________
OFFICIAL 4-H HEALTH AND CODE OF CONDUCT FORM
 ADULT
Rev. 10/12
County: JACKSON
 YOUTH
Participant's Name:
Jackson
Last
First
Street Address
City
M.I.
Address:
County
Oregon
Participant is an Adult, ___ Male .___ Female ____
State
Home phone:
Emergency Contact:
(541)
Name
Zip Code
Cell phone:
Relationship
(541)
Daytime phone
Evening phone
Health Statement (to be completed by parent, physician or adult participant):
Is the participant currently under medical treatment? (describe)
Yes
No
Is the participant diabetic?
Yes
No
Does the participant have any history of respiratory illness? (describe)
Is the participant subject to seizures of any kind?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Date of last tetanus shot?
Is there any medical condition (heart condition, etc.) or malformation now existing that may require treatment or affect the participant's participation in this program?
Has the participant had recent surgical operations or accidents or been exposed to infectious disease within the last two weeks?
(Please bring notification to the activity if this changes prior to the event)
Does the participant have any allergies or dietary restrictions? If yes, please describe:
Name of all medications:
Name and phone number of physician:
Accommodations*: OSU and the 4-H Youth Development Program do not discriminate against otherwise qualified participants with disabilities on the basis of disability, Are there any accommodations that you are
requesting in order to participate in the 4-H Youth Development Program? Yes ____, No ____ If yes, please describe:
.
*Accommodations may include: speech, hearing or vision impairments that may effect participation, behavior disorders or emotional disturbances or abnormally severe moodiness, sleepwalking, and the ability to carry heavy objects,
participate in strenuous travel or physical labor.
ADULT VOLUNTEER EXPECTATIONS
The purpose of the Volunteer Agreement is to help insure the safety and well-being of all Oregon State University Extension 4-H program participants.. The opportunity to represent OSU Extension Service
and work with 4-H youth is a privileged role to be held by those who are willing to agree to behaviors that fulfill this trust. As a volunteer in the OSU 4-H Youth Development Program, I agree to…
1. Focus on the educational mission of the land grant university, including the equal
opportunity and anti-discrimination policies. (“4-H programs are accessible without
regard to race, color, religion, gender, sexual orientation, national origin, age, marital
status, disability, and veteran status.”)
2. Obey local, state, federal laws. Follow specific guidelines established for county, state,
and national 4-H programs.
3. Accept support and/or supervision from Extension program staff of designees.
4. Treat others courteously. Be a positive role model. Exhibit good sportsmanship.
5. Establish and maintain safe environments for all participants. Act responsibly to protect
participants.
6. Provide for physical and emotional needs of participants during programs. Not withhold
necessities nor use physical punishment. Communicate that verbal, emotional or
physical mistreatment is unacceptable within the program. Report suspect ted abuse to
protect those who cannot protect themselves.
7. Not consume alcohol or be under its influence while responsible for 4-H programs or
youth. .
8. Handle funds and fundraising in an ethical manner and in accordance with federal, state
and university regulations. (Fundraising activities must be approved by Extension staff.
4-H funds are public assets, need to be expended for educational purposes, and must
not be a part of a private individual’s bank account.)
9. Handle equipment and machinery in a safe and responsible manner. Operate vehicles
only with a valid operator’s license and the legally required insurance coverage.
10. Treat animals humanely and provide them appropriate care. Teach youth to do the
same.
MY SIGNATURE BELOW INDICATES THAT:
• I have read, understand and agree to the OSU Extension Service 4-H Adult Volunteer Expectations above. I understand and agree that any action on my part that contradicts any portion of
these expectations may be grounds for non-acceptance, suspension, or termination of my volunteer role with OSU 4-H Youth Development programs.
• I hereby give permission to the medical personnel selected by the person in charge of the 4-H event to order x-rays, routine tests, treatment, release any records necessary, and to provide or
arrange necessary related transportation for the person named on this form. I hereby give permission to the physician selected by the person in charge of the 4-H event to hospitalize, secure
emergency treatment for, to order injection, anesthesia, and/or surgery for me or my child as named on this form. I will assume all financial obligations incurred if not covered by insurance.
Leader Signature:
Date:
MEDIA RELEASE: I give permission to use my image in videotape, audiotape, film photography , or in any other medium for educational, fundraising, or promotional purposes related
to the Oregon 4-H program. I understand that such images may be published in a variety of ways, including, but not limited to, print and electronic formats. In addition, I give
permission to release my name and hometown to news media for recognition purposes. Leader signature_______________________________________________________________