Fillable Nh 4-H Member Enrollment Form (Page 2 of 3) in pdf

Club Information

Club Name

Category:

Type of Club

(choose one)

Do you Belong to a 2nd 4-H Club?

Cloverbud

Community Club

If so, please list name:

(4-H Age 5-7 years

In -School Club

)

old as of Jan 1

After-School Club

Do you have siblings in 4-H?

Member

Military Club

If Yes, please list name(s)

(4-H Age 8-18 years

old as of Jan 1)

Independent Member

Please see Project Enrollment Form for Project Selection

Media Release

4-H event participants may be photographed and videotaped for use in 4-H promotional and educational materials which may include

Yes

use on web pages or social media. I authorize 4-H to record the above named 4-H member’s image and/or voice for use by the

University of New Hampshire, its affiliates (including but not limited to the UNH Cooperative Extension, UNH Foundation, and a 4-H

Foundation of New Hampshire), or its assignees in research, educational and promotional programs. I understand and agree that these

audio, video, film, and/or print images may be edited, duplicated, distributed, reproduced, broadcast and/or reformatted in any form

and manner without payment of fees, in perpetuity.

NH 4-H Code of Conduct

As a participant in a New Hampshire 4-H Event, you have the responsibility of representing the NH 4-H program to

the public. You are expected to conduct yourself in a manner that will bring honor to you as well as to 4-H. To do that you will need to:

1. Attend all sessions in the planned program and participate fully.

7. Know that the use of illicit drugs, alcohol, tobacco and fireworks are

2. Follow established hours and room rules. YOU are responsible for

prohibited at all 4-H events.

knowing the rules of your event.

8. Treat program areas, lodging areas and transportation vehicles with

3. Dress appropriately for each event. (follow the dress code when

respect and care. You will be responsible for any damage, theft or

given)

misconduct in which you participate.

4. Use language and manners that are appropriate for a 4-H event. You

9. Help other persons in your group have a pleasant experience by

are responsible for knowing what language and behavior is

making every attempt to include all participants in all activities.

appropriate.

10. Live up to your highest expectations for yourself so you can return

5. Be in the assigned program area at all times (eg. dorms, motels, etc)

home proud of who you are and what you have done.

6. Model respect for other persons in public areas.

Those who find themselves unable to conduct themselves within the guidelines listed above may expect:

1. To explain their actions to the adults in charge.

4. To possibly be excluded from participation in a future 4-H event/trip.

2. To accept the consequences of their actions.

5. To have the adults in charge notify parents/guardians, Extension staff

and others to see that the actions taken in case of unacceptable behavior

3. To possibly be sent home immediately at their own expense.

are appropriate for all concerned.

4-H Activity Youth Permission and Release

I understand that the above named 4-H member will be participating in the New Hampshire 4-H program. The activities are supervised primarily

by volunteers and include active, hands-on activities that occur at local, county, statewide national venues. We understand the responsibilities,

hazards, and dangers inherent in participation in the program, including transportation. We give permission for the above named youth to

participate. It is the policy of UNH Cooperative Extension never to sell or share information with outside agencies. We may share information

with other 4-H leaders or UNH staff within the county or state for the purpose of planning and promoting events.

We hold harmless the University of New Hampshire, its trustees, officers, agents, employees, and volunteers from and against all claims,

demands actions, and causes of action for damages which may be sustained by the above named youth or anyone else. This includes personal

injury, death or property damage, whether or not the result of negligent acts or omissions on the part of the University of New Hampshire. If the

above named youth’s participation in the activity causes damage to any property where a UNH Cooperative Extension program is being held we

agree to pay the property owner for such loss.

I am the parent/guardian and approve my child’s enrolling with 4-H:

Parent/Guardian Signature

Date

Member Signature

Date

Leader Signature

Date

Please print and mail completed form to your local county office

(click down arrow to select county office below)

Click down arrow to select county office

University of New Hampshire Cooperative Extension is an

Questions? Visit:

equal opportunity educator and employer.

10/2015

Nh 4-H Member Enrollment Form Page 2

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