Voluntary Release Of Liability, Hold Harmless, Indemnification, Assumption Of Risks, And Informed Consent For Water Sports Activities Form/alabama 4-H Youth Consent Form Page 3
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VERIFICATION
Alabama 4-H Youth Code of Conduct
I, _________________________________________
(parent/guardian)
I will exhibit good character and behavior, such as
understand that participants will be supervised and that if a
trustworthiness, responsibility, respect, caring,
serious illness or injury develops, medical and/or hospital
citizenship and fairness.
care will be given. I hereby give permission to the attending
I will value the rights of all others. As a 4-H member, I
physician or other health care professional to hospitalize,
am committed to the policies of the Alabama
secure proper treatment for, and order injections,
Cooperative Extension System, Auburn University and
anesthesia, or surgery for me or my child and affirm that the
Alabama A&M University.
information set forth in the Health History is true and correct
I will act and speak respectfully. I will not use language
to the best of my knowledge and belief. I understand that as
that belittles others or is disrespectful of individual
a parent/legal guardian, I will be responsible for the cost of
differences.
service or treatment.
I will dress appropriately. Apparel including accessories
4-H Member Signature ____________________________
must not have pictures or wording involving nudity, sex,
weapons, violence, drugs, alcohol or tobacco.
Date ________________________
Apparel, accessories and equipment featuring culturally
or racially insensitive images violates 4-H’s values of
Parent/Guardian Signature ________________________
respect, fairness and caring and will not be permitted.
Date ________________________
I will attend all sessions of planned programs.
I have read and understand the Alabama 4-H Youth Code
I will be responsive to the reasonable requests of
of Conduct, Publicity Release and Survey & Evaluation
leaders and comply with the need for personal safety.
Release.
I will not use alcohol, drugs, or tobacco nor remain in
the presence of anyone using them.
4-H Member Signature ____________________________
I will not behave recklessly, engage in sexual
Date ________________________
misconduct, assault, threaten, or harm another person
or abuse public or private property.
Parent/Guardian Signature ________________________
When I have access to computers at Extension
Date ________________________
facilities, I will use the computer for educational
purposes and will not access inappropriate Web sites.
I hereby agree that I understand the risks or have been
I recognize that these guidelines are not all inclusive
given the opportunity to ask for information concerning risks
involved in this activity and assume all risks and release
and that the Alabama Cooperative Extension System
Alabama 4-H, the Alabama Cooperative Extension System,
may make adjustments to these policies.
local Extension offices, Auburn University, Alabama A & M
University, the State of Alabama, the Alabama 4-H
MEMBER: I have read the Alabama 4-H Youth Code of
Conduct and agree to live up to the expectations. I realize
Foundation and 4-H Youth Development Center, and their
trustees, agents, officers and employees, from all claims,
my failure to do so could result in a loss of privileges during
the event and/or in the future and may result in my being
demands, and causes of action of any kind, including
claims of negligence, which may arise from participation of
sent home at the expense of my parent(s) or guardian(s).
me or my minor child in any Alabama 4-H sponsored
4-H Member Signature ____________________________
activity, and this release is specifically granted in
consideration of the services, programs and activities.
Date ___________________________________________
4-H Member Signature ____________________________
Date _______________________
SURVEY & EVALUATION RELEASE
Parent/Guardian Signature ________________________
I hereby give permission for my child (under 19 years
Date ________________________
of age) and give consent for myself, as a parent or
guardian, to complete surveys and evaluations that will be
Issued in furtherance of Cooperative Extension work, acts of May 8 and June
used to determine program effectiveness or to promote the
30, 1914, and other related acts, in cooperation with the U. S. Department of
program. I understand that participation in surveys and
Agriculture. The Alabama Cooperative Extension System (Alabama A & M
University and Auburn University) offers educational programs, materials,
evaluations is voluntary and that I and my child may choose
and equal opportunity employment to all people without regard to race, color,
not to participate and may withdraw from surveys or
national origin, religion, sex, age, veteran status, or disability.
evaluations without impact on my or my child’s eligibility to
participate in the 4-H program. I understand that I or my
child may be asked for consent before completing a survey
or an evaluation.
No, I am not willing to participate – or give permission
for my child to participate – in any program evaluation.
This form is valid for one year from signing. Please update all medical or other information as needed.
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