4-H Academy Registration Step 1 of 5 20% Which 4-H Academy pathway are you signing up for?*HorsePhotographyLeadershipGlobal Positioning System (GPS)EnvironmentalPersonal InformationName* First Last Email* Date of Birth* Age as of January 1*Please enter a value greater than or equal to 13.Gender*FemaleMaleContact InformationHome Address* Street Address City State ZIP Phone Number* Registration QuestionsT-Shirt Size*SmallMediumLargeX-Large2XLPursuant to the Americans with Disabilities Act, do you require specific aids or services?*YesNoPlease describe:Do you have any special dietary needs?*YesNoPlease fill out the special dietary form at https://rocksprings.net/things-to-do/meals-dining/allergy-request/ to ensure you/your child will have meals made to their needs. Kansas 4-H Participation FormFor youth registrations, the Kansas 4-H Participation Form section must be completed by a parent or guardian. I authorize K-State Research and Extension and the Kansas 4-H Foundation or their assignees to record and photograph my/my child's image or voice for use in research, educational and promotional programs. I also recognize that these audio, video, and image recordings are the property of K-State Research and Extension and/or Kansas 4-H Foundation.*I AgreeI DO NOT AgreeI understand that, if a serious illness or injury develops in a participant, emergency medial and/or hospital care will be given. I hereby give my permission to the attending physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for me/my child and affirm that the information set forth in the Health History is true and correct to the best of my knowledge and belief. I understand that no insurance is provided and that I will be responsible for the cost of medical services. I hereby release Rock Springs 4-H Center, the Kansas 4-H Foundation, Inc., local Extension Councils and Districts, Kansas State University, the state of Kansas, and their agents, officers, and employees, from all claims, demands, and causes of action of any kind (up to and including death,) including claims of negligence, that may arise from my/my child's participation in any Kansas 4-H sponsored activity, and this release is specifically granted in consideration of the services, programs and activities that involve horses, provided by Rock Springs 4-H Center and being allowed to participate.*I AgreeParent/Guardian Electronic Signature*As a participant in the Kansas 4-H program, you have the responsibility of representing Kansas 4-H to the public. You are expected to conduct yourself in a manner that will bring honor to you, your family, and 4-H. To do that, you must: 1. Conduct yourself and your project work in a manner that is trustworthy, respectful, fair, caring, and in good citizenship. 2. Be responsible for your actions by following the rules and being accountable. This includes being in assigned program locations/sessions, abiding by deadlines, times, and housing arrangements. If you are unable to participate or need assistance, notify those in charge of the event/program. 3. Treat yourself, other people, animals, and property with respect, using good manners, dressing appropriately, and by not using profanity. You will be personally responsible for any damage caused a result of your behavior. 4. Know that the use of tobacco, alcohol, and non-prescribed drugs by youth is illegal. 5. Demonstrate caring for people other than yourself. Know that harassment of any type is illegal and prohibited at all 4-H events. 6. Be a good citizen by participating fully, and helping those around you have positive experiences. 7. Use technology and social media in safe and appropriate ways for the good of 4-H Youth Development programs. *I AgreeParticipant Electronic Signature*Parent/Guardian Electronic Signature* Health HistoryA parent or guardian is responsible for completing this section for their child. Reporting health conditions will not prevent a person from attending and will be kept confidential. Please indicate if any of the following health conditions apply to the participant.* Asthma Auto Immune Disease Seizures/Convulsions Diabetes Hypoglycemia Hypertension Heart Condition Migraines Stoke History Serious Insect Stings Serious Ivy, Oak, or Sumac Poisoning Drug Allergies Food Allergies Other Serious Allergies or Reactions Recent Injury or Surgery Other Conditions Wears Glasses/Contact Lenses None of the Above Date of Last Tetanus Shot* If any health conditions are indicated above, please explain and provide information to include special or dietary needs and/or activity restrictions for yourself/your child. If there are none, please enter NA.*Please list your/your child's current medications, including rescue medications such as inhalers and/or EPI pens. If there are none, please enter NA.*Please list an additional information or concerns regarding you/your child's physcial, mental, emotional and or, social health so that we can help you/your child participate in 4-H. If there are none, please enter NA.*MedicationsPlease indicate which over-the-counter medications may be administered to your child without contacting you:* Antihistamine (Benadryl) Antacid Ibuprofen (Motrin) Acetaminophen (Tylenol) Decongestant Dramamine Hydrocortisone Polysporin (topical antibiotics) No over-the-counter medications may be given to my child unless I am contacted first Medical InformationDo you/does your child have Health Insurance?*YesNoName of Family Doctor*Family Doctor's Phone*Health Insurance Company*Policy #*Name of Insured*Relationship to Participant*Emergency ContactsEmergency Contact 1 - Name* First Last Emergency Contact 1 - Phone Number*Relationship to Participant*Emergency Contact 2 - Name First Last Emergency Contact 2 - Phone Number*Relationship to Participant* Payment4-H Academy Camp Registration* Price: $335.00 Quantity: Total $0.00 By submitting this registration, I understand that if I cancel on or before June 1, 2019, I will be subject to a $25.00 Cancellation Fee*I understandCredit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.