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A Special Thank to Our Program Partners Adair- Casey Community Schools

Adair County 4-H Youth Council

Adair County Board of Supervisors

Adair County Fair Board

Adair Public Library

Adair County Sheriff, local law enforcement and firefighters

Adair County Vet Clinic – Dr. Gary Schulteis

Boys and Girls Club of Central-Southwest Iowa

E.E. Warren Opera House Association(Warren Cultural Center)

Empowering Adair County Foundation

Fontanelle Public Library

Greenfield Public Library

Nodaway Valley Community Schools

Orient-Macksburg Community Schools

Public Resource Technology Center, Orient

Southwestern Community College/Southwest Iowa STEM Hub

Stuart-Anita Veterinary Clinic, PC

Stuart Public Library

West Central Valley Community Schools

MEET THE 2015 SUMMER STAFF

We are excited to announce you will see some familiar faces this summer.

Kelsie Kralik, Brad Baudler, Jesse McCann, and McKinzie Boes are all returning to lead summer day camps!

Bradley Baudler is currently an Iowa State student majoring in Elementary Education with endorsements in math and reading. During the year, he works for America Reads/Counts where he tutors students grades Kindergarten to 2nd at Ballard West Elementary in math and reading. Brad also wants to become a high school coach and works with the ISU Women’s Basketball team during their season. This will be Brad’s third year back with summer programs and he is enthusiastic for camps to start!

McKinzie Boes will graduate from the University of Northern Iowa Spring 2016 with a degree in Secondary History Education. McKinzie works with kids of all ages through her college jobs at a local preschool and through coaching young softball players. This will be her second summer with the Adair County Extension summer program, and she is excited to make connections with the kids again and create even more memories this summer!

Kelsie Kralik is a 2013 graduate of Northwest Missouri State University with a degree in Elementary Education and an endorsement in reading and a concentration in social studies. Kelsie is currently teaching 5thgrade in the CAM school district. She is excited to join the staff again this summer in planning and leading camps and can’t wait to see what fun the summer will bring!

Jesse McCann is a 2014 graduate of Northwestern College in Orange City with a degree in Elementary Education with endorsement in special education and coaching. Jesse is currently a High School Special Education teacher at Southwest Valley School in Corning. He is excited to be back for a second year at Adair County Extension!

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Signing Up

Adair County Extension places a high value on meeting the needs of students. All programs are designed to address youth needs of belonging, independence, generosity and mastery. Programs feature hands-on individual and group learning experiences in a fun, relaxed setting. Participants have a chance to gain new knowledge and enhance their skills in communication, teamwork, and decision making. Getting involved is simple and rewarding.

Read each camp description; they provide information on topic, time, location, and cost. All grade levels are the grade the student will be entering Fall 2015. For more information about any program, contact the Adair County Extension office at 641-743-8412 or email powella@iastate.edu.

Visit with your child; pick out the experience(s) that suit their interests and your family’s schedule. If the cost of the program is a barrier to your child’s participation, need-based scholarships are

available. The scholarship form is available on the back of the registration form included in this booklet. The names of scholarship recipients are kept confidential. No one except the program administrator will have access to the information.

Complete a registration form and medical information/release form. If your child needs to take medication at camp, you will also need to complete a special permission form. All forms must have a parent/guardian’s signature. Return the completed forms with payment to the Adair County Extension office at 154 Public Square, Suite C, Greenfield, IA 50849. If you are requesting a scholarship, be sure to complete the scholarship form on the back side of the registration form; do not include any payment if you are requesting a scholarship (an invoice will be sent to you at a later date after scholarship status is confirmed).

All programs have limited enrollment. Registration will be accepted until maximum capacity has been met or up to one week before the program, whichever comes first.

Mark your calendar with the programs that you sign up for. A reminder will be provided approximately one week prior to the program. You may select to receive the reminder via e-mail, text message, and/or mail.

Notes about lunch at full day camps

Campers need to bring their own lunch to all day-long camps, unless it is otherwise designated in the

camp description. Beverages (milk and water) are provided.

When packing lunch we encourage a protein source (i.e. meat, cheese, or peanut butter sandwich),

a grain, fresh fruits and veggies.

Snacks are provided during the day so please limit high sugar desserts and/or candy type items.

Questions or Concerns?

If you have any questions or concerns, please feel free to contact Angie Engles at the Adair County

Extension Office by calling 641-743-8412 or by e-mailing powella@iastate.edu.

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ADAIR COUNTY EXTENSION 2015 SUMMER PROGRAMS SCHEDULE

DATE PROGRAM NAME TIME GRADE FALL 2015

LOCATION *COST

June 3 & 4 Livestock Corral 9:30 am-3:30 pm 5th-8th Adair County Fairgrounds/ Anita Vet Clinic

$12.50

June 7-10 Southwest Iowa Junior Camp

6th-7th 4-H Camping Center, Madrid $225

June 8-11 Unmask Series 9:30-11:30 am 1st-5th Greenfield Public Library FREE

June 8-11 Unmask Series 1:30-3:30 pm 1st-5th Adair Public Library FREE

June 15-18 Unmask Series 9:30-11:30 am 1st-5th Stuart Public Library FREE

June 15-18 Unmask Series 1:30-3:30 pm 1st-5th Fontanelle Public Library FREE

June 15,16,17,19 Unmask Series 9:30-11:30 am 1st-5th Orient PRTC (Library) FREE

June 17-18 SOFA Trip 8th-12th South Dakota FULL

June 22-24 Around the World 9:30-12:00 pm 5th-8th 4-H/FFA Center, Adair County Fairgrounds

$15

June 22-24 Science Sleuths 1:00-3:30 pm 5th-8th 4-H/FFA Center, Adair County Fairgrounds

$15

June 30-July 2 State 4-H Conference 9th & up ISU Campus, Ames $175

July 6 Clover Kids Camp 9:30 am-3:30 pm Current Clover Kids

Adair County Fairgrounds, Greenfield

**

July 7 Springbrook 1 9:30 am-5:00 pm 5th-8th Springbrook State Park $15

July 8 Springbrook 2 9:30 am-5:00 pm 5th-8th Springbrook State Park $15

July 9 Super Chefs 1 9:30 am-3:30 pm 1st-4th NVHS FCS Room, Greenfield $20

July 10 Super Chefs 2 9:30 am-3:30 pm 1st-4th NVHS FCS Room, Greenfield $20

July 15-19 Adair County Fair All Ages Adair County Fairgrounds ***

July 23 Unmask Your Creative Side 1:00-3:30 pm 5th-8th Warren Cultural Center Green Room

$5

July 27-30 Wild Reading 9:30 -12:00 pm 1st-4th 4-H/FFA Center, Adair County Fairgrounds

$17.50

July 27-30 Nimble with Numbers Math 1:00-3:30 pm 1st-4th 4-H/FFA Center, Adair County Fairgrounds

$17.50

July 31 Fun with Friends 1 9:30 -12:00 pm 1st-3rd Warren Cultural Center Green Room

FREE

July 31 Fun with Friends 2 1:00-3:30 pm 4th-6th Warren Cultural Center Green Room

FREE

* Need-based partial scholarships are available. Complete scholarship application form on back of registration form.

** For current Clover Kid members only

*** Adults (any over 12) - $7/day or $30/5 day wristband; Kids (ages 5 – 12) $4/day or $15/5 day wristband. The fair

board provides a complimentary 5-day wristband to each 4-H and FFA county fair exhibitor. Discovery, summer program

participants, and FFA members without livestock or crops projects who exhibit only in the 4-H and FFA Center will also

receive a complimentary 5-day wristband when they bring their exhibit on Wednesday.

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All grades are based on the grade child will enter in Fall 2015.

Entering 1st -3rd Grades Camp # Unmask (Greenfield) 1 Unmask (Adair) 2 Unmask (Stuart) 3 Unmask (Fontanelle) 4 Unmask (Orient) 5 Super Chefs 1 6 Super Chefs 2 7 Clover Kids Camp (current kids) 8 Wild Reading 9 Nimble with Numbers 10 Fun with Friends 1 11

Entering 4th Grade Camp #

Unmask (Greenfield) 1 Unmask (Adair) 2 Unmask (Stuart) 3 Unmask (Fontanelle) 4 Unmask (Orient) 5 Super Chefs 1 6 Super Chefs 2 7 Clover Kids camp (current kids) 8 Wild Reading 9 Nimble with Numbers 10 Fun with Friends 2 12

Entering 5th Grade Camp #

Unmask (Greenfield) 1 Unmask (Adair) 2 Unmask (Stuart) 3 Unmask (Fontanelle) 4 Unmask (Orient) 5 Fun with Friends 2 12 Unmask Your Creative Side 13 Livestock Corral 14

Entering 5th Grade (cont) Camp #

Around the World 15 Science Sleuths 16 Springbrook 1 17 Springbrook 2 18

Entering 6th Grade Camp #

Fun with Friends 2 12 Unmask Your Creative Side 13 Livestock Corral 14 Around the World 15 Science Sleuths 16 Springbrook 1 17 Springbrook 2 18 SWIA Jr Camp

Entering 7th Grade Camp #

Unmask Your Creative Side 13 Livestock Corral 14 Around the World 15 Science Sleuths 16 Springbrook 1 17 Springbrook 2 18 SWIA Jr Camp

Entering 8th Grade Camp #

Unmask Your Creative Side 13 Livestock Corral 14 Around the World 15 Science Sleuths 16 Springbrook 1 17 Springbrook 2 18

Entering 9th grade and above State 4-H Conference

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2015 Summer Learning Experiences (All grades are based on the grade the child will enter in Fall 2015)

_____________________________________________________________________________

UNMASK YOUR OPPORTUNITIES SERIES

For: 1st – 5th grades Dates: Check sites below Times: Check sites below

Location: Check sites below Cost: FREE

Minimum: 5/site Maximum: 25/site

Grab your superhero mask and cape! It’s time to become a super reader! Complete a super hero training camp

and learn how to fight crime while becoming a great reader during this 4 day camp.

1. Greenfield Public Library

Monday-Thursday, June 8-11

9:30-11:30 am

2. Adair Public Library

Monday-Thursday, June 8-11

1:30-3:30 pm

3. Stuart Public Library

Monday-Thursday, June 15-18

9:30-11:30 am

4. Fontanelle Public Library

Monday-Thursday, June 15-18

1:30-3:30 pm

5. Orient Public Library (Public Resource/Technology Center)

Monday, Tuesday, Wednesday, June 15, 16, 17 & Friday, June 19

9:30-11:30 am

A special thanks to Public Libraries in Adair County for partnering with

Adair County ISU Extension to host “Unmask Your Opportunities” Series.

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SUPER CHEFS

For: 1st-4th grades

Dates: Check sites below Times: Check sites below

Location: Check sites below Cost: $20, includes lunch

Minimum: 8/session Maximum: 16/session

Future chefs will get to make their own lunch and snacks at this day long camp. Spend time preparing the meals, along with learning through fun activities that will keep you moving. Due to popular demand, we will be offering two sessions of Super Chefs. Pick the one that works best for your family’s schedule.

6. Super Chefs 1 Date: Thursday, July 9 Time: 9:30am – 3:30 pm Location: NV High School FCS Room

7. Super Chefs 2 Date: Friday, July 10 Time: 9:30am – 3:30 pm Location: NV High School FCS Room

8. Clover Kids Camp

For: *CURRENT Adair County Clover Kid members

Date: Monday, July 6

Time: 9:30 am-3:30 pm

Location: Adair County Fairgrounds, Greenfield

Cost: cost included with annual membership

Wrap up your year in Clover Kids with this fun all-day camp. Put together your head, heart, hands, and health while participating in fun hands-on projects. You can even exhibit these projects as a Clover Kid at the 2015 Adair County Fair.

*Due to the high number of current Adair County Clover Kids, the camp is only open to those enrolled in the Clover Kids program during the school year. For information about joining Clover Kids for Fall 2016, contact Adair County Extension.

9. Wild Reading**

For: 1st-4th grades Date: Monday-Thursday, July 27-30 Time: 9:30 am-12:00 pm Location: 4-H/FFA Center, Adair County Fairgrounds, Greenfield Cost: $17.50 Minimum: 8 Maximum: 30 Be ready to get wild while learning about animals during this week long camp. Explore “wild” animals through reading, games, songs, and more.

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10. Nimble With Numbers** For: 1st-4th grades Date: Monday-Thursday, July 27-30 Time: 1:00-3:30 pm Location: 4-H/FFA Center, Adair County Fairgrounds, Greenfield Cost: $17.50 Minimum: 8 Maximum: 30

Become “nimble with numbers” during this week long math camp. Campers will use fun games to become nimble with basic math facts.

**Supervision is offered over the lunch hour for those campers enrolling in both Wild Reading and Nimble with Numbers. Campers will need to bring their own sack lunch.

FUN WITH FRIENDS

For: See grades below Date: Friday, July 31 Times: See sites below Location: Warren Cultural Center Cost: FREE: Thanks to support from an Empowering Adair County Foundation grant through the

Adair County 4-H Youth Council Minimum: 8/session Maximum: 30/session

This half day camp led by Adair County 4-H Youth Council members will help kids learn what it takes to be a good friend. You will get to have fun celebrating with each other and creating long lasting friendships.

11. Fun With Friends 1

For: 1st-3rd grades Date: Friday, July 31 Time: 9:30 am-12:00 noon

12. Fun With Friends 2

For: 4th-6th grades Date: Friday, July 31 Time: 1:00-3:30 pm

13. Unmask Your Creative Side

For: 5th-8th grades Dates: Thursday, July 23 Times: 1:00-3:30 pm Location: Warren Cultural Center Green room Cost: $5: Thanks to support from Warren Cultural Center/Greater Greenfield Foundation Minimum: 8 Maximum: 16

Make your own painting to take home. Local Art Teacher Alexa Hoffman will lead you through the steps to paint your own scene on a canvas with your friends. Warren Cultural Center will be offering a painting session for adults the evening of July 23. For additional information on the evening session, contact WCC at 641-343-7337.

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14 Livestock Corral

For: 5th-8th grades

Dates: June 3 & 4

Times: 9:30 am-3:30 pm Location: 6/3: Adair County Fairground 6/4: Anita Vet Clinic Cost: $12.50 Minimum: 4 Maximum: 12

Learn how to care for animals ranging in size from rabbits to cattle. Watch experienced showmen demonstrate techniques in exhibiting animals and hear from a local Vet. On the second day, you will get to visit the Anita Vet Clinic.

15. Around The World

For: 5th-8th grades Date: Monday, June 22- 24 Time: 9:30 – 12:00 noon Location: Adair County Fairgrounds, Greenfield Cost: $15.00 Minimum: 8 Maximum: 24

Campers will explore countries from all around the world through playing traditional games, eating traditional food, and learning traditional music from each country.

16. Science Sleuths For: 5th-8th grades Date: Monday, June 22- 24 Time: 1:00-3:30 pm Location: Adair County Fairgrounds, Greenfield Cost: $15.00 Minimum: 8 Maximum: 24

Use science to solve the “Mystery of the Disappearing Diamonds” during this camp! During camp, kids will explore the field of forensic science and perform experiments to determine which of the four suspects is responsible for stealing the precious stones.

**Supervision is offered over the lunch hour for those campers enrolling in both Around the World and Science Sleuths. Campers will need to bring their own sack lunch.

SPRINGBROOK ADVENTURE

For: 5th – 8th grades Dates: Choose a session below Time: 9:30 am – 5:00 pm Location: Springbrook State Park (depart from NV High School) Cost: $15 Minimum:16/session Maximum: 24/session

If you love the outdoors, this trip is for you! Picnic at Springbrook State Park before an afternoon of activities. You will get to kayak, practice archery, go on a scavenger hunt. We are offering 2 trips to Springbrook. Choose the one below that works best for you. 17. Springbrook 1: Tuesday, July 7 18. Springbrook 2: Wednesday, July 8

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ADDITIONAL SUMMER OPPORTUNITIES

The following are not a part of the Adair County ISU Extension ‘Unmask’ Summer Program

and require a separate registration.

SW IOWA AREA 4-H JUNIOR CAMP

Dates: Sunday – Wednesday, June 7 – 10

Location: Iowa 4-H Camping Center, Madrid

Open to: Youth entering 6th-7th grades Fall 2015

Registrations due May 22

Cost: $185– Adair County 4-H’ers are eligible for a 50% rebate funded by the 4-H Booster fund.

http://www.extension.iastate.edu/harrison/news/2015-5th-6th-grade-4-h-junior-camp

Iowa 4-H Youth Conference – “Dare to Discover”

Dates: June 30-July 2 Location: Iowa State University, Ames Open to: Youth entering 9th grade and up (both 4-H and non 4-H members can attend) Registrations due online by May 30 http://www.extension.iastate.edu/4h/iowa4hyouthconference Cost: $175 Adair County 4-H’ers attending conference for the first time are eligible for a 75% rebate; those who have attended conference previously are eligible for a 50% rebate. You’ll meet new friends, enjoy motivational speakers, dances, banquets, workshops, and complete a service project.

ADAIR COUNTY FAIR

Dates: Wednesday, July 15 – Sunday, July 19 Costs: Adults - $7/day or $30/5 day wristband

Kids (ages 5-12) $4/day or $15/5 day wristband. http://www.adaircountyfair.org/ The Adair County Fair Board will be charging gate admission all 5 days of the fair this year starting on Wednesday, July 15 (1 day earlier than past years). The fair board provides a complimentary 5-day wristband to each 4-H and FFA county fair exhibitor. Discovery, summer program participants, and FFA members without livestock or crops projects who exhibit only in the 4-H and FFA Center will also receive a complimentary 5-day wristband.

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For Ext. Office use only: # Date Received: Payment/Notes:

Adair County Extension Summer Program Registration 2015 (Please complete one form for each participant) Participant Name ________________________________________________ Grade entering Fall 2015 _____ Phone 1: ________________________ Phone 2: ______________________ Mailing Address ________________________________________________________________________________ Please provide program reminders via: (Check all that apply & provide additional information.) Email: __________________________________________________________________ Text message: Cell number ___________________ Provider: ___US Cellular ___Verizon ___Other:________________ Mail: (if different than above address) ________________________________________

Place a checkmark next to the programs your child would like to participate in (be sure to check program descriptions for grade eligibility). Early registration is encouraged.

All programs have an enrollment capacity limit. Slots will be filled on a first come/first serve basis. All registration forms must be submitted at least one week in advance.

1.Unmask Your Opportunities Greenfield June 8-11 FREE

2.Unmask Your Opportunities Adair June 8-11 FREE

3.Unmask Your Opportunities Stuart June 15-18 FREE

4.Unmask Your Opportunities Fontanelle June 15-18 FREE

5.Unmask Your Opportunities Orient June 15, 16, 17, 19 FREE

6.Super Chefs 1 NVHS, Greenfield July 9 $20

7.Super Chefs 2 NVHS, Greenfield July 10 $20

8.Clover Kids Camp Fairgrounds, Greenfield July 6 *

9.Wild Reading Fairgrounds, Greenfield July 27-30 $17.50

10.Nimble With Numbers Fairgrounds, Greenfield July 27-30 $17.50

11.Fun with Friends 1 (1st-3rd) WCC, Greenfield July 31 FREE

12.Fun with Friends 2 (4th-6th) WCC, Greenfield July 31 FREE

13. Unmask Your Creative Side WCC, Greenfield July 23 $5

14.Livestock Corral Fairgrounds, Greenfield June 3 & 4 $12.50

15.Around the World Fairgrounds, Greenfield June 22-24 $15

16.Science Sleuths Fairgrounds, Greenfield June 22-24 $15

17.Springbrook 1 Springbrook State Park July 7 $15

18.Springbrook 2 Springbrook State Park July 8 $15

TOTAL DUE:

* Free for current (2014-2015) Clover Kids __________________________________ _______________________________________________ Parent Signature Preferred listing of parent name(s) (please print)

Return this completed form, medical/information release form**, and payment to: Adair County Extension, 154 Public Square, Suite C, Greenfield, IA 50849

**If child is taking medication, Request for Giving Medication Form must be completed. Make checks payable to: Adair County Extension

For more information, contact the Extension Office at 641-743-8412 or 1-800-ISUE399 or e-mail powella@iastate.edu .

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Need-based scholarships are available. If your family meets free or reduced price school lunch guidelines and you wish to take

advantage of the scholarship program, complete the scholarship form below.

Do not submit payment until you are notified of adjusted amount.

Complete this form only if you wish to be considered for a scholarship.

SCHOLARSHIP APPLICATION

All children who meet the income guidelines for the school’s free and reduced lunch program are eligible for partial

scholarships to participate in summer programming.

If you wish to apply for a need-based scholarship for your child/ren to participate in Extension summer programming,

please complete the following release. (If your child is not enrolled in school, you will need to verify eligibility by

providing page 1 of your 2013 tax return or a copy of child’s current Title XIX card.)

I, ____________________________________________________________________, authorize

(check the school your child attends or write in a blank space for other)

Adair-Casey Community Schools

Nodaway Valley Community Schools

Orient-Macksburg Community Schools

West Central Valley Community Schools

Other: _________________________________

to release information concerning my child’s participation in the free and reduced lunch program to Adair County

Extension Office in order to determine eligibility for summer program scholarships.

__________________________________________ __________________________

Signature Date

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Keep original in County Office.

Iowa 4-H Medical Information/Release Form

(Non 4-H Club Members - Youth)

2015 Summer

PARTICIPANT INFORMATION

Participant’s Name

Permanent Address Date of Birth Gender

City, State, Zip Home Phone MEDICAL EMERGENCY CONTACT INFORMATION

Person to Contact First Backup Contact (Relative or Friend)

Name Name

Relation to Participant Relation to Participant

Daytime Phone Daytime Phone

Evening Phone Evening Phone

E-mail E-mail

Name of Family Doctor Office Number

Name of Dentist Office Number

INSURANCE POLICY INFORMATION The above-named participant is covered by health insurance. Yes** No*

* If no, initial this line stating that you do not have health insurance and are aware that Iowa State University/University Extension/4-H does not

carry any health insurance for you. ** If yes, provide the following information which is required by Iowa State University to expedite treatment and to facilitate the billing process.

Policy Holder’s (P.H.) Name P.H.’s Date of Birth

Address Relation to Participant

City, State, Zip Occupation

P.H.’s Employer’s Name/Address

Insurance Company Name

Policy # Plan #

HEALTH INFORMATION (Please Print) Does the child have any of the following conditions or a history of any of the following conditions? (Check all that apply.) Asthma Bronchitis Fainting Spells Diabetes Ear Infections Heart or cardio-vascular problems/disease Convulsions/seizure Hay Fever Chronic bone, muscle or joint injuries Migraine headaches Other condition(s): (Please list)_______________________________

Allergies or reactions: (Check all that apply.) Aspirin Penicillin Dairy Gluten Peanuts Insect bites or stings Ivy/oak/sumac toxins Other (list) ___________________________ Is your child currently on any prescribed or over-the counter medication? (If so, please record the condition/ailment, name of

medication, dosage, time(s) of day, prescribing physician.)

________________________________________________________________________________________________

Date of last tetanus shot (approximate if necessary):_________________________________ (over)

4H-3039B-Y

August 2012 rev

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. . . and justice for all

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national

origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to

all programs.) Many materials can be made available in alternative formats for ADA clients. To file a complaint of discrimination, write

USDA, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call

202-720-5964.

Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of

TO BE READ AND SIGNED BY PARTICIPANT

BEHAVIOR EXPECTATIONS OF THE PARTICIPANT

It is important to follow the directions of the adult leader(s) at all times. I understand that as a participant I have the responsibility to help make the activity a safe experience for everyone through my behavior and conduct. I also understand the danger of not following rules and directions and agree to follow them. Participant Signature Date

TO BE READ AND SIGNED BY PARENT OR GUARDIAN

I understand that my child must be healthy and reasonably fit in order to safely participate in 4-H recreation activities and that I will inform the program leader(s) of any medication, ailment, condition, or injury that may affect his/her ability to participate safely.

MEDICAL EMERGENCY PARENTAL PERMISSION*

The health history for my child is correct and complete to my knowledge. If an injury or other medical condition occurs or arises, I hereby give permission to the ISU Extension staff or volunteer to provide routine first aid and seek emergency treatment including x-rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing or insurance purposes. I understand that I am financially responsible for charges and hereby guarantee full payment to the attending physicians or health care unit. In the event of an emergency where I cannot decide for my child, I give permission to the physician/hospital selected by the ISU Extension staff or volunteer to secure and administer treatment for my child, including hospitalization. (*If you cannot sign this section of the form for any reason, contact the County Extension Director regarding a legal waiver in order to attend and participate.)

_________initial __________date

PUBLICITY/IMAGE/VOICE PERMISSION

The Iowa State University Extension 4-H Program normally takes photographs, video, and/or tape recording of our programs. During activities, a photograph or video/audio recording may be taken of you or your child. Unless you request otherwise, your initial below will be considered permission for Iowa State University and the 4-H Program to photograph, film, audio/video tape, record and/or televise your image and/or voice or the image and/or voice of your child for use in any publications or promotional materials, in any medium now known or developed in the future without any restrictions. If you object to ISU using you or your child’s image or voice in this manner, please notify the adult leader. _________initial __________date

TRANSPORTATION I am giving my permission for my child to be transported during an authorized activity or event. I give my permission for: (Check all that apply.)

My child to ride with any adult volunteer driver. My child to ride with an authorized adult volunteer driver who has completed an MVR check. My child to ride in another youth’s (18 or younger) vehicle to 4-H activities. My child to drive his/her vehicle to 4-H activities or events. My child to transport other 4-H participants in his/her or my vehicle.

I understand that if personally-owned vehicles are used as transportation to and from Iowa State University (ISU) 4-H events or activities, that the owner of the vehicle is responsible for any liability that might occur during the transportation. ISU does not provide coverage for any property damage, personal injury or liability that may occur while using personal vehicles. Vehicle owners are required to carry automobile liability insurance as required by the State of Iowa.

_________initial __________date

4-H ASSUMPTION OF RISK AND RELEASE OF LIABILITY (Please read carefully.)

I give permission for to participate in the 4-H program. I understand that 4-H project activities/events may involve certain risks of physical activity and possible injury and that Iowa State University and its 4-H program will provide each participant with reasonable care, but that ISU cannot guarantee that my child will remain free of injury. In addition, some 4-H projects including but not limited to: shooting sports, horse or livestock projects, water activities, and other sporting activities have a higher degree of risk. I nonetheless wish to have my child participate in the 4-H program and ASSUME the RISK of participating. I agree to RELEASE from LIABILITY, INDEMNIFY and HOLD HARMLESS the State of Iowa, the Board of Regents of the State of Iowa, ISU and ISU Extension and their officers, employees and agents (hereinafter the RELEASEES) from any and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my child’s participation in the 4-H program. This release, however, is not intended to release the above-mentioned RELEASEES from liability arising out of their sole negligence. Parent or Guardian Signature Date

(Must be signed by the parent or guardian if the participant is under 18 years old)