Macon County 4-H Mini-Camp: The Joy of Art and Nature

Participant Name (Each child needs to be registered separately)

Age of Participant

Grade of Participant

Is the youth a 4-H member? Yes/No If, Yes please list 4-H Club if applicable

I am registering for Event Name on Event Date(s) *you may select multiple dates/cost is per child per each event

How did you hear about this program?

Do you need any support or accommodations to particpate in the program? Early requests are encouraged to allow sufficient time for meeting access needs.

Please list any food allergies, sensitivities, or health conditions you have that we should be made aware of.

Please list any questions you would like answered during the event.

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 old. 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.

I would like to discuss a fee waiver for the following program. Please select all that apply