Heart of a Champion Livestock Show - Participation Registration
Please complete and submit this form by February 19, 2023
Event will be held on Friday, March 1, 2024 starting at 4:30PM
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First Name
 *
Last Name
 *
Sex *
Mailing Address *
City *
Zip *
Birth Date *
MM
/
DD
/
YYYY
Age *
School, if applicable. 
A parent or guardian must be present during the duration of the Heart of a Champion Livestock Show.
Parent or Guardian 1 Name *
Parent or Guardian 2 Name
 *
Primary Phone *
Primary Email *
Emergency Contact *
Emergency Contact Phone *
Relationship to Emergency Contact *
Primary Doctor (Name & Contact Information) *
Special Needs Information
Nature of Disability *
Does the participant use a walker, wheelchair, or crutches? *
If yes, which one? 
Shirt Size - Each Volunteer is required to wear a shirt during the duration of the event.  *
Rank your preference of animal 1-6.
Rabbit *
Goat *
Dog *
Pig *
Sheep *
Chicken *
Release and Consent for Medical Treatment
Please read carefully, then initialize each statement.
I agree and understand that by this acknowledgement that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my acknowledgement on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement. I  affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions. 
 *

I, the parent/guardian of the registrant, agree that I and the registrant will abide by the rules of Wise County 4-H and Texas A&M AgriLife Extension Service. Recognizing the possibility of physical injury associated with livestock and in consideration for the Wise County 4-H and Texas A&M AgriLife Extension Service accepting the registrant for its livestock show and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify Wise County 4-H and Texas A&M AgriLife Extension Service, its affiliated organizations, board and sponsors, their employees and associated personnel, including the owners of the livestock utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.

As the parent or legal guardian of the above named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions necessary to preserve the life, limb or well-being of my dependent *
Release and Consent to Photography and Videography

I, the parent/guardian of the registrant, hereby give my consent for photography/videography and the use of said photographs to be displayed on website, Facebook, or other means of advertisement expressly for the enrichment of the Heart of a Champion Livestock Show.

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Please initial below to acknowledge the release and consent of photography and videography.  *
Special comments or requests.
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