Parental Release Form
I, __________________________________ (parent/guardian) give my son/daughter/ward,
______________________________, (child’s name) permission to participate in the University
of Illinois Extension’s Gettin’ Buggy Day Camp on August _________, 2008.
I understand that:
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The event will take place at the University of Illinois Extension, Naperville Office: 1100 E.
Warrenville Road, Suite 170, Naperville, IL 60563.
University of Illinois Extension and its volunteers cannot be held responsible for any
physical injuries that may be sustained by my son/daughter/ward as a result of
participation in the Gettin’ Buggy Day Camp.
My son/daughter/ward is expected to act with good character/behavior while
participating in this program.
The staff of University of Illinois Extension are authorized to obtain the appropriate
emergency medical treatment, should my son/daughter/ward require it, and in such
event, I request that the following contact person and telephone number be called
immediately:
__________________________________________
Name

_______________________
Phone
There will be a $20 charge per youth to cover expenses for the activities.
___ I have enclosed $20 with this signed permission form.
___ I paid by Credit Card online.
Any questions? Call Heather Britton, Learning Enrichment Coordinator, 4-H
Youth Program at 630-955-1123 x18. Registration deadline is July 25, 2008.
Parent or Guardian’s Signature
__
Date:___________
4-H Photo and Video Release
University of Illinois Extension would like to take photographs and videotape your child while they
participate in 4-H/Horticulture activities. We will use these images to tell others about our 4-H/Horticulture
programs. We would like your permission to do this.
I grant the 4-H Youth and Horticulture Program, conducted by University of Illinois Extension, permission
to take photographs and videotape recordings of my child while she/he participates in the Gettin’ Buggy
Day Camp.
I grant the University of Illinois Extension permission to use these photographs taken during the program
to share information about the program with other professionals working with youth and those interested
in the programs of University of Illinois Extension. I understand my child’s name will not be used.
I grant the University of Illinois Extension 4-H and Horticulture Program permission to share comments
my child makes during the 4-H program with other professional working with youth and those interested in
the programs of University of Illinois Extension.
Parent or Guardian’s Signature
__
Date:___________
Youth Emergency Medical Form
Child’s Name: ________________________________________________________________
___________________________________________________________________________
Street Address
City
State/Zip Code
Grade: ______ Sex: ____ Ethnicity: _________ Date of Birth: ________/________/_________
Parent/Guardian: _____________________________________________________________
Home Phone: (______) ______-___________
Work Phone: (______) ______-___________
____________________________________________________________________________
Street Address
City
State/Zip Code
Parent/Guardian: _____________________________________________________________
Home Phone: (______) ______-___________
Work Phone: (______) ______-___________
____________________________________________________________________________
Street Address
City
State/Zip Code
Health Conditions or Food Allergies:
Medications:
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
Primary Care Physician: ______________________________________________________
Clinic/Hospital Affiliation: _____________________________________________________
City: ____________________________ Phone: (______) ______-___________
Health Insurance Provider: _____________________________________________________
Primary Insured Name: _______________________ ID/Policy Number: ___________________
As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital
care will be given. I further understand that in case of serious illness/injury, I will be notified.
However, if it is impossible to contact me, I give my permission for emergency treatment, x-ray
or surgery, as recommended by an attending physician. I also understand that any accident
insurance in effect for the 4-H program does not cover preexisting conditions or self-inflicted
injuries.
Parent or Guardian’s Signature:
___________Date:________