Clark Co. Cooking for Kids 4-H SPIN Club CONFIDENTI!

"O#TH $E%IST$TION & E'E$%ENC" 'EDIC! INFO$'TION

'ail (o) #ni*+rsi(, of Illinois E-(+nsion-Clark Coun(,-./401 N. S(a(+ H2,. .-'ars3all4 I! 5644.
6.7-865-/466
"ou(3 Par(i9i:an()
;Firs( Na<+= ;'.I.= ;!as( Na<+=
%+nd+r) 'al+ F+<al+ "+ars in 4-H if 9urr+n( 4-H <+<b+r)
Par+n(>s Na<+)
;Firs( Na<+= ;'.I.= ;!as( Na<+=
ddr+ss) Ci(,) ?i:)
P3on+) Ho<+ C+ll S+9ondar, P3on+ Nu<b+r)
@ir(3da(+) / / %rad+ Co<:l+(+d)
<o. da, ,+ar
$+sid+n9+ ;93+9k on+= Rural/Small Town (town under 10,000 or rural) Farm (income is from farming)
S:+9ial N++dsADi+(ar, $+s(ri9(ions: ______________________________________________
Parent/Guardian Photo/Video/Audio Release
Yes No I grant the University of Illinois Extension 4-H Youth Program, irrevocable permission to recor an!or isclose my chil"s
ientity, image, an voice arising out of ocumenting 4-H youth programs an to use, reprouce an istribute such in #hole or
in part in vieo an!or soun recorings, films, photographs, transparencies, #ebpages, social meia, local ne#s meia or any
other meia for any purpose on behalf of the University an Extension #ithout compensations to me an #ithout any right for
me to inspect or approve of the finishe photograph, vieo, or auio recorings or other recorings$
I will be attending !oo"ing for #ids$ at: _____ !ase% _____ &ars'all
$+gis(ra(ion F++ En9los+d (!'ec"s made (a%able to )ni*ersit% of Illinois +,tension)-
_____ ./0 (for current 012 members) _____./3 (non1012 members)
Please contact the Extension Office if financial assistance is needed.
E'E$%ENC" CONTCTS)
4ame: __________________________________________________________________________________
Relations'i(
2ome 5'one: _(______)_________1______________ 6or" 5'one: _(______)_________1______________
4ame: __________________________________________________________________________________
Relations'i(
2ome 5'one: _(______)_________1______________ 6or" 5'one: _(______)_________1______________
%ignature &ate '''''''''''''''''''
Ethnicity
Hispanic or (atino Yes No
Race) (select one)
*merican Inian! *las+an Native ,hite
*sian - or .ore /aces
0lac+ or *frican *merican %ome 1ther
/ace
Native Ha#aiian or Pacific Islaner
Family Military Affiliation
None *rmy Navy
*ir 2orce *rmy National 3uar Navy /eserve
*ir National 3uar *rmy /eserve 4oast 3uar
*ir 2orce /eserve .arine 4orps 4oast 3uar /eserve
.arine 4orps /eserve
Clark Co. Cooking for Kids 4-H SPIN Club CONFIDENTI!
HE!TH INFO$'TION STTE'ENT
!'ec" below an% information %ou feel staff and/or *olunteers ma% need, to ma,imi7e t'e safet% and t'e well1being of
t'e %out'- To t'e rig't of t'e condition statement is s(ace for more information relating to t'e condition c'ec"ed-
5lease be s(ecific- In case of emergenc%, t'is 'ealt' information ma% be t'e onl% source of accurate, im(ortant
information-
8 9 :llerg% to Foods____________________________________________________________________
__________________________________________________________________________________
8 9 !am( staff s'ould be aware of t'ese additional medical conditions_____________________________
__________________________________________________________________________________
8 9 :llerg% to &edicines (including (enicillin, tetanus) ____________________________________

8 9 !urrentl% ta"ing &edicines (list names ; doses) _______________________________________
______________________________________________________________________________
8 9 )nder on1going care of a 5'%sician (4:&+ ; 52<4+ =) for c'ronic or recurring (roblem
______________________________________________________________________________
Primary 4are Physician) ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
4linic!Hospital *ffiliation)''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
4ity) '''''''''''''''''''''''''%tate) ''''''''''''''Phone) 5''''6''''''''''''''''''''''
Health Insurance Provier) '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
1#ner"s Name) '''''''''''''''''''''''''''''''''''' I&!Policy Number)''''''''''''''''''''''
Medical Privacy Statement:
It is the policy of University of Illinois Extension 4-H Youth evelopment Pro!rams to "eep any medical information it may have
re!ardin! 4-H Youth evelopment pro!ram participants confidential# Ho$ever% there may &e time in $hich such
medical information $ill &e needed and may need to &e shared $ith others# Examples of sharin! mi!ht include: providin!
information to medical personnel in the event of an emer!ency so that a youth may &e treated' providin! information to Extension
staff or volunteers $ho are coordinatin! specific events in the case of a re(uest for reasona&le accommodation' and providin!
information to chaperones or host families $ho are responsi&le for the health and safety of pro!ram participants at a specific event#
Except in the case of emer!ency% prior to sharin! any medical information% it may have $ith those external to the University%
Extension% or 4-H% every effort $ill &e made to !et the permission of the pro!ram participant or parent or !uardian$
*s a parent or guarian, I unerstan that if a serious illness!in7ury evelops, meical or hospital care #ill
be given$ I further unerstan that in case of serious illness!in7ury, I #ill be notifie$ Ho#ever, if it is
impossible to contact me, I give my permission for emergency treatment, x-ray or surgery, as recommene
by an attening physician$
I also unerstan that any accient insurance in effect 5I2 P/18I&E&6 for the event oes not cover pre-
existing conitions or self-inflicte in7uries$
%I3NE&)''''''''''''''''''''''''''''''''''' &*9E)''''''''''''''''''''''''''
Parent or 3uarian
Issued in furtherance of Cooperative Extension Work, Acts of May 8 and une !", #$#%, in cooperation &ith
the '.(. )epart*ent of A+riculture, ). ,. Ca*pion, )irector, 'niversity of Illinois Extension, 'niversity of
Illinois at 'r-ana.Cha*pai+n. /he 'niversity of Illinois Extension provides e0ual opportunities in pro+ra*s
and e*ploy*ent. 1/he %.2 Clover is Protected 'nder #8 '.(.C. 3"3.