I understand and agree that my child (Participant named above) is sufficiently healthy and reasonably fit to safely participate in the Iowa 4-H program.  I understand and agree to inform program leader(s) of any condition that may affect my child’s ability to safely participate in the Program, and to work with program leader(s) to develop a written safety plan regarding my student if I have such concerns. 

I recognize that there may be occasions where my child may be in need of first aid or emergency medical or dental treatment as a result of an accident, illness, or other health condition or injury. Therefore, I authorize Iowa State University (the University), Iowa State University Extension and Outreach staff, County Agricultural Extension District staff, representatives, and volunteers to provide routine first aid and to seek emergency medical treatment for my child, including consenting to x‐rays, examinations, and other medical diagnoses and treatments. I agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my child that may occur during their participation in the Program. As parent or legal guardian of my minor child, I am authorized to consent to the services to be rendered and I represent that my consent to and agreement to pay for medical and/or hospital care or treatment is legally sufficient and that no consent from any other person is required.  In addition, I agree to hold harmless and agree to indemnify the State of Iowa, the Board of Regents for the State of Iowa, the University, Iowa State University Extension and Outreach, County Agricultural Extension District, and their staff, representatives, and volunteers from any claims, causes of action, damages and/or liabilities, arising out of or resulting from said medical treatment. 

I give my permission for myself and/or my youth to participate in the Iowa 4-H program.  I understand that 4-H club project activities/events may involve certain risks of physical activity and possible injury and that Iowa State University (ISU) and its 4-H program will provide each participant with reasonable care, but that ISU cannot guarantee that I or 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 myself or my child participate as an Iowa 4-H club member in the 4-H club program and ASSUME the RISK of participating.

I hereby RELEASE FROM LIABILITY AND COVENANT NOT TO SUE, the State of Iowa; the Board of Regents for the State of Iowa; Iowa State University; Iowa State University Extension and Outreach, and the County Agricultural Extension District, and all of their respective officers, employees, agents, and volunteers (the “Releasees”) from any and all liability, claim and/or cause of action arising out of or related to any loss, damage or injury, including death, that may be sustained by myself or my child, or to my property resulting, in whole or in part, from my own or my child’s participation in the Program, to the fullest extent permitted by law.  In addition, the undersigned, on behalf of themselves and any personal representatives, heirs, assigns, and next of kin, HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS the Releasees from any and all liability for injury, including illness, disability, and death, and property loss or damage that may result from, arise out of, or be related to my own or my child’s participation in the Program, to the fullest extent permitted by law.

I HAVE READ THIS AGREEMENT IN FULL, AND I UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

BEHAVIOR EXPECTATIONS of the Participant:  

It is important to follow the directions of the staff and volunteers in charge of programs at all times.  I must also abide by Iowa State University Extension and Outreach’s rules and conduct expectations.  I understand that, as a participant, I have the responsibility to help make the learning opportunity 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.

I agree to follow the Code of Conduct for Iowa 4-H Youth and Families found at the following link: https://iastate.box.com/v/webdoc4HP3410.   

I understand that if personally-owned vehicles are used as transportation to and from Iowa State University (ISU) 4-H Club 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.

I am giving my permission for my child to be transported during an authorized 4-H activity or event.