Fishing Derby at 4-H Memorial Camp

Welcome to the Fishing Derby at 4-H Memorial Camp. Join us for fishing, fish cleaning, a chance for prizes and a campfire with hotdogs and smores. Participants are welcome to bring their own fishing gear. No experience is necessary. The fishing should be great for those avid to fish one last time before winter arrives. This fishing derby will be a great opportunity to catch and release one of the many large bass living in the 16-acre lake. Participants may keep a small number of bluegill and black crappie. A self-guided Nature Trail hike through the vibrant fall forest will be available for those not wishing to fish, along with a few other outdoor activities such as gaga ball.

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Contact Information

First Name

Last Name

Street Address

Street Address 2

City

State

ZIP

Daytime Phone

Evening Phone

E-mail Address

1st Participant Name, Gender, Age Children with birthdays after September 2021 are free and may fish with the held of an accompanying adult.

2nd Participant Name, Gender, Age

3rd Participant Name, Gender, Age

4th Participant Name, Gender, Age

5th Participant Name, Gender, Age

6th Participant Name, Gender, Age

FEE: Please make your selection below. If registering more than 6, please contact Eric at erice@illinois.edu.

1 participant ($10.00)

2 participants ($20.00)

3 participants ($30.00)

4 participants ($40.00)

5 participants ($40.00)

6 participants ($40.00)

Extension Participant/Volunteer AGREEMENT TO ASSUME RISKS AND FULLY RELEASE ALL CLAIMS Extension Volunteer Agreement to Assume Risk/Approved for legal form by OUC/LMP/092018 Risks of Extension Activities. I understand that my participation in University of Illinois Extension activities can present risks of physical injury (including death or disability) to me and damage to my personal property. The University of Illinois does not guarantee my personal health or safety or protect me against property loss. Physical injury to me or property damage may result from known or unexpected risks arising from things such as: use of equipment, materials, or facilities; environmental conditions, including poisonous plants, insects, and extreme heat or cold and other weather-related hazards; natural disasters; water activities; transportation; actions of others; animal behaviors; unavailability of immediate or adequate emergency care; infectious diseases; and slips and falls. Risks of 4-H Equine Activities. Equine (horse, pony, mule, donkey, or hinny) activities present dangerous risks of injury and harm, regardless of the safety measures taken. If a horse or other equine animal is frightened or provoked, I understand that it might ignore its training and act according to its natural survival instincts, which may include actions such as unexpected change of directions or speed; running; sudden movement or stopping; shifting weight; bucking; rearing; kicking; and biting. I understand that UNDER THE ILLINOIS EQUINE ACTIVITY LIABILITY ACT, EACH PARTICIPANT WHO ENGAGES IN AN EQUINE ACTIVITY EXPRESSLY ASSUMES THE RISK OF ENGAGING IN AND LEGAL RESPONSIBILITY FOR THE INJURY, LOSS, OR DAMAGE TO PERSON OR PROPERTY RESULTING FROM THE RISK OF EQUINE ACTIVITIES. Risk of equine activities means dangers including but not limited to: (1) propensity of an equine to behave in ways that may result in injury, harm or death to persons on or around them; (2) unpredictability of an equine’s reaction to sounds, sudden movement, and unfamiliar objects, persons, other animals or other things; (3) certain hazards such as surface and subsurface conditions; (4) collisions with other equines or objects; and (5) the potential of a participant to act in a negligent manner that may contribute to injury, such as failing to maintain control over the animal or not acting within his or her ability. Risks of 4-H Shooting Sports Activities: Shooting sports involve the use of firearms, live ammunition, or archery equipment. I understand that there are inherent dangers associated with my participation in shooting sports, including observation. The potential dangers include, among other things, gunshot or archery wounds that can result in paralysis or loss of vision, limb, or life. Assumption of Risks and Release of Claims: In consideration for allowing me to participate in Extension activities, I voluntarily assume all risk of injury and loss that I may sustain or suffer in connection with my participation in the activities described in this Agreement, and I forever and fully release, waive, and discharge all claims, demands, actions, and causes of action, known or unknown, that I have or that may accrue to me in the future (“Claims”) against the Board of Trustees of the University of Illinois, its officers, employees, agents, and volunteers (individually a “Releasee”) for personal injuries (including death), damage to property, and all liabilities, losses, costs, and expenses (including attorney fees) arising out of or resulting from my participation in Extension activities, including all Claims arising, in whole or in part, from the negligence of any Releasee. This Agreement is binding on my heirs, assigns, and representatives. Effective Date: This Agreement is effective on the date signed by me (“Effective Date”) and replaces any similar agreements previously signed by me as to Extension activities that occur on or after the Effective Date.

Yes, I consent

Talent Release/Waiver for minors and children under the age of 18 I, the undersigned, on behalf of the minor child named below, do hereby consent to the use by The Board of Trustees of the University of Illinois (“University”) of the minor’s 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 image or voice, or both, of the named minor, 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, and 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.

Yes, I consent.

No, I do not consent.

Signature line will be in PDF confirmation.

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Street Address

City

State

Zip Code

Best Contact Day Phone Please use format xxx-xxx-xxxx in case of emergency, we will contact you at this phone number.

Best Contact Evening Phone Please use format xxx-xxx-xxxx Please use format xxx-xxx-xxxx In case of emergency, we will contact you at this phone number. If it is your cell phone, we suggest that you add the 4-H Camp phone number to your contacts. (217) 762-2741

Parent/Guardian Email Address Please use an email that is your best contact or that you use on your smart phone. We will use this email to send you a confirmation of registration, send your packing list information as well as any important updates or alerts. Any news regarding your child's camp session will FIRST be sent by email, so please use one that you check often. This should be the same email as listed in the contact information at the beginning of the registration.

Alternate Contact First Name In the event of an emergency, if we cannot reach the parent, please list an additional person that we may contact.

Alternate Contact Last Name

Relationship to Participant

Alternate Contact Phone Number Please use format xxx-xxx-xxxx

Alternate Contact Email Address

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Total Registration Cost $