Outdoor Awareness Registration

"*" indicates required fields

Step 1 of 3

Youth Name*

First Last

Age (as of date of program)*

Please enter a number from 8 to 14.

Date of Birth (MM/DD/YYYY)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

Parent/Guardian Name*

Contact Number (if different than above)

Email Address (if different than above)

I, hereby give my consent as the parent/guardian of my child/children, for his/her involvement in the Outdoor Awareness at Claiborne West Park. OC 4-H staff and adult volunteers will provide supervision. I hereby release, waive, Indemnify and hold harmless Orange County 4-H and its agents/representatives in the events of injury to my child/children, and hereby waive, release and forever discharge any and all rights and claims against them. I further understand that Orange County 4-H or its representatives will not provide any form of medical insurance and that Orange County 4-H or its agents/representatives will not be responsible for any expenses incurred as a result of injury, illness, loss or accident, to the person(s) or property of my child/children, while attending this function. In case of an emergency, I give the agents/representatives of Orange County 4-H permission to secure emergency care for my child/children in my absence.*

Parent First Name Parent Last Name

I (give/do not give) permission to have my child’s picture published on websites, newspapers, Facebook, etc.*

Give Permission

Do Not Give Permission

I understand that if the behavior of my youth causes any disruption in the planned activity, I will be called at once to come and pick up my youth immediately at the site of the activity.*

First Last