Youth Registration Form - Gallatin County, Montana

2013 Gallatin County 4-H Junior Master Gardener
Youth Enrollment Form
Last Name:____________________________________ First Name__________________________________ M.I._______
Address:_____________________________________ City___________________________ State________ Zip________
Youth E-mail: _______________________________________ Youth Cell Phone: _______________________________
School:__________________________________ Grade ______
Gender:_______ Birthday_______/_____/_______
Ethnic (Circle one): Hispanic Not Hispanic
Race (Circle one): White Black Asian Amer. Ind./Alaskan
White & Black White & Asian White & Amer. Ind./Alaskan
Black & Amer. Ind./Alaskan Hawaiian/Pac. Island
Other Mix
Parent / Guardian Information
GALLATIN COUNTY 4-H
201 WEST MADISON, STE 300
BELGRADE, MT 59714
Residence (Circle one): Farm Rural-under 10,000 Town-between 10,000-50,000
Media Release:
I, (parent/guardian name)_________________________________________________________________,
(please initial one as the parent/guardian) authorize OR do not authorize Gallatin County
MSU Extension Service to use photograph(s) of my child that were taken during a 4-H related event or
activity on the Extension Website, press releases, newsletters, and other publicity related to 4-H
activities.
The Extension Office will not use personal details or full names (first and last) of any child in a photograph
on our web site. We will not include personal e-mail or postal addresses, telephone or fax numbers
on our website or in other printed publications. We may use the name of the child in accompanying
text or a photo caption. We may use group or photographs with very general labels. We will only
use images of children in suitable dress, to reduce the risk of inappropriate use of images.
I hereby release the Gallatin County 4-H Program, Montana State University and any photographer
chosen by them to photograph my child from any and all claims for damages for libel, slander, invasion
of privacy or any other claim based upon the use of my child’s photograph and information about
him/her for this purpose. Signed____________________________________________________________
MOM: (Legal guardian?_____Yes _____No) DAD: (Legal guardian?_____Yes _____No)
Name_____________________________________________ Name___________________________________________
Address:__________________________________________ Address_________________________________________
City, ST, Zip______________________________________ City, ST, Zip_____________________________________
E-mail Address___________________________________ E-mail Address__________________________________
Home Phone: (_______) _______-_______________ Home Phone: (_______) _______-_______________
Cell Phone: (_______) _______-_______________ Cell Phone: (_______) _______-_______________
Occupation (optional): ____________________________ Occupation (optional): __________________________
Work Phone (______) _______-_______________ Work Phone (______) _______-_______________

2013 Junior Master Gardener
4-H Summer Program
Youth Registration Form
Learn the basics of gardening through hands-on activities in the school gardens.
Prepare snacks using garden produce following a Farm to School theme.
Complete activities toward receiving your official Junior Master Gardener certification.
Program includes JMG book, workshop supplies, snacks, and a JMG T-shirt.
Eligible ages: Grades 3‐5
Times: 9:00 AM–2:00 PM (Drop off starting at 8:30 AM)
Location: Hyalite Elementary School
Bring your OWN lunch!
Sliding scale suggested donation to cover supplies: $60-$100
Please make checks payable to: “Gallatin County 4-H”
2013 JMG Sessions offered:
(Choose one)
M-F July 15 — 19
M-F July 22 — 26
M-F July 29 — August 2
First Name:______________________ M.I. ______ Last Name_____________________________
Have you previously taken any JMG workshops? Yes or No
Do you already own a Junior Master Gardener Book? Yes or No
Describe allergies or medical concerns we should be aware of:
Describe dietary or other considerations we should be aware of:
T-shirt size:
(Select one)
Youth XS Youth XL
Youth S Adult S
Youth M Adult M
Youth L Adult L
Please complete the Junior Master Gardener 4-H Enrollment Form on the reverse side
as well as the Medical Release Form and FoodCorps Media Release Form. To guarantee preferred
t-shirt size, please mail or drop off forms with sliding scale donation payment by July 1, 2013 to:
Gallatin County Extension Office
201 West Madison, Suite 300
Belgrade, MT 59714
For questions about the Junior Master Gardener 4-H Summer Programs, contact Erin Jackson at
erin.jackson@foodcorps.org
For questions about enrollment, contact the Gallatin County Extension/4-H Office at
gallatin1@montana.edu, phone—406-388-3213, fax—406-388-3243
The U.S. Department of Agriculture (USDA), Montana State University and the Montana State University Extension prohibit discrimination in all of
their programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and
marital and family status. Issued in furtherance of cooperative extension work in agriculture and home economics, acts of May 8 and June 30,
1914, in cooperation with the U.S. Department of Agriculture, Jill Martz, Director of Extension, Montana State University, Bozeman, MT 59717

REGISTRATION FOR THE JMG SUMMER PROGRAM CANNOT BE ACCEPTED WITHOUT
COMPLETED HEALTH FORM FOR EACH YOUTH ATTENDING JMG 4-H SUMMER PROGRAMS
Participant Information:
Medical Release Form for 4-H Youth & Adults
Name: ____________________________________________________ County: ____________________
Address: _______________________________________________ City: __________________ State: __
Name of Parent of Legal Guardian: _________________________________________________________
Physician: __________________________________________________ Phone: ____________________
Dentist: ____________________________________________________ Phone: ____________________
In Case of Emergency:
Contact: ______________________________________________________________________________
Phone: _____________________ Cell Phone: _____________________ Work: _____________________
Address: _____________________________________________________________________________
Alternate Contact: ______________________________________________________________________
Phone: ____________________ Cell Phone: _____________________ Work: ______________________
Address: ______________________________________________________________________________
Insurance Information:
Name of Insurance Carrier: _______________________________________________________________
Policy Number: _________________________________________________________________________
Date of Last:
Tetanus Shot __________ Polio Shot __________ Mumps Shot __________
Measles Shot __________ Rubella Shot __________

Medical Information: (check all that apply and explain if checked)
Respiratory problems: _____________________________________________________________
Heart Disease: __________________________________________________________________
Stomach or intestinal problems: _____________________________________________________
Diabetes or hypoglycemia (low blood sugar): __________________________________________
Nervous disorder (convulsions, epilepsy, dizziness, etc) __________________________________
Any Allergies to Food or Plant: ______________________________________________________
Are you allergic to bee stings? Yes No Don’t know
Special diet or food restrictions: _____________________________________________________
Are you currently under a doctor’s care? Yes No
If Yes, Explain: __________________________________________________________________
Are you currently taking medications? Yes No
If Yes, Explain: ________________________________________________________________________
Any physical restrictions or other medical problems that may require special considerations? Yes No
If Yes, Explain: ________________________________________________________________________
Authorization for Treatment:
I, _______________________________ do hereby give permission to the Junior Master Gardener 4-H
Parent or Guardian
Summer Program Director/FoodCorps Director, other 4-H Volunteer Staff, 4-H Agent, and other Extension/4-
H Staff, to seek and obtain any medical care necessary for my child ___________________________during
my absence. Child’s Name
Parent/Guardian Signature _________________________________________ Date_________________
To the best of my knowledge, accurate information has been provided in all areas of this form.
Youth Participant Signature _____________________________________________ Date ____________
Parent/Guardian Signature ______________________________________________ Date ____________

Dear Parent or Guardian:
Parent or Guardian Video & Photography Release Form
Below you will find a form granting permission to FoodCorps, Inc. and those authorized by Food-
Corps, Inc. to interview, videotape and photograph your child during FoodCorps activities, and
granting FoodCorps the right to own such interview materials, videotapes, and photographs.
Please review this form, sign and return with your Junior Master Gardener Program forms. With
questions, contact your child’s FoodCorps Service Member Erin Jackson at
erin.jackson@foodcorps.org.
FoodCorps is a nationwide team of leaders that connects kids to real food and helps them grow up healthy.
FoodCorps service members will be at your child’s school this year teaching students about healthy food
and where it comes from, growing school gardens and getting healthy food into the cafeteria.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
I authorize FoodCorps or its agents to interview, videotape, audiotape or photograph my child at activities hosted by
FoodCorps and any related in-school activities. I understand that FoodCorps may use such interview material, photographs
or video or audio recordings that include my child for public relations, news articles or telecasts, education, advertising,
research, inclusion on the FoodCorps website, fundraising and other purposes. I grant and convey to Food-
Corps all right, title and interest in all such interview materials, photographs, or video or audio recordings, and I waive
any right that my child or I may have to inspect or approve such media or how it is used. I also agree that I will not seek
royalties in connection with any recordings, photographs, or other media that includes my child, nor will I seek any other
compensation for my child’s participation in the activities described in this form.
By signing below, you indicate that you are a parent or legal guardian of the child listed below, that
you have read and understand this form, and that you acknowledge that it is legally binding.
Printed Name of Child:
__________________________________________________________________
School of Child:
___________________________________________________________________
Printed Name of Parent or Guardian:
___________________________________________________________________
Signature of Parent or Guardian: Date:
_________________________________ ______________________
☐ I DO NOT authorize FoodCorps or its agents to interview, videotape, audiotape or photograph my child