4-H Fall Vegetable Garden Harvest Workshop

Would you like to participate in the 4-H Fall Vegetable Garden Harvest Workshop?

Participant name:

What age is the participant?

What grade is the participant in?

Is the participant a 4-H Member?

If the participant is a 4-H Member, which club? *if not a 4-H Member please input N/A

Photo/Talent Release: I, the undersigned, do hereby consent to the use by The Board of Trustees of the University of Illinois (“University”) of my image, voice, or both described below, in (1) the video, photograph, or audio recording described below; and (2) any video, photograph, or audio recording reproduced either in whole or in part from the video, photograph or audio recording described below: regardless of whether these materials are used for fundraising, advertising, publicity, or any other purpose on behalf of either the University or its Foundation. I warrant that I have the full right and authority to grant this consent. In addition, I waive all claims to compensation or damages based on the use of my image or voice, or both, by either the University or the Foundation. I also waive any right to inspect or approve the finished photograph or video or audio recording. I understand that this consent is perpetual, that I may not revoke it, and that it is binding on me, my heirs and assigns. I warrant that I am at least 18 years of age and that I am competent in my own name insofar as this consent is concerned, or that I am the parent or legal guardian authorized to sign on behalf of a person under age 18. I further attest that I have read this consent form and fully understand its contents. Do you consent to this form?

First and Last Name/Signature of Talent (or parent/legal guardian if under 18): *By entering your name you consent to the release of all video/photo/audio recorded during this program. | If you do not consent, please input N/A.

Please list any questions you would like answered during this event. *if none please input N/A

Please list any food allergies, sensitivities, or health conditions your child may have that we should be aware of. *if none please input N/A

Do you need any support or accommodations to participate in this program? *early requests are encouraged to allow sufficient time for meeting access needs. | If none please input N/A

How did you hear about this program?