1100 E. Warrenville Road, Suite 170 Naperville, IL 60563 Phone: 630-955-1123 Fax: 630-955-1180 www.extension.uiuc.edu.edu/dupage 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 _________, 2009. I understand that: 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. There is a limit of 40 youth for this program per day. 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 Any questions? Call Heather Britton, Learning Enrichment Coordinator, 4-H Youth Program at 630-955-1123 x18. Registration deadline is July 28, 2009. 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: (___) _____-_________Cell: (__)_____-_______ ____________________________________________________________________________ Street Address City State/Zip Code Parent/Guardian: _____________________________________________________________ Home Phone: (____) ______-________Work: (___) _____-_________Cell: (__)_____-_______ ____________________________________________________________________________ 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:________ University of Illinois Extension University of Illinois * United States Department of Agriculture * Local Extension Councils Cooperating University of Illinois Extension provides equal opportunity in programs and employment If you need reasonable accommodation to participate, please contact Heather Britton at least 2 weeks prior to the event.