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Iowa State University Extension and Outreach does not discriminate on the basis of age, disability, ethnicity, gender identity, genetic information, marital status, national origin, pregnancy, race,

religion, sex, sexual orientation, socioeconomic status, or status as a U.S. veteran. Direct inquiries to the Diversity Officer, 515-294-1482, extdiversity@iastate.edu.

What Can Your Child Expect To Do In Clover Kids? • Participate in activities uniquely suited to their de-

velopment

• Grow and Learn in a non-competitive

environment

What Is Clover Kids?

Clover Kids is a FUN youth program specially designed for children in grades 1-3. The focus is on hands on and cooperative learning in small groups. Clover Kids participate in STEM activities, games, and other positive experiences in a supportive, creative, challenging and fun environment.

PARTICIPANT INFORMATION

Participant’s Name _______________________________________Email:______________________________________

Permanent Address _________________________________ Date of Birth ____________________ Gender _______

City, State, Zip _____________________________________ Grade _____ Phone______________________________

Parents Names: _____________________Are you of Hispanic ethnicity? N or Y Race:__________ Reside: Farm or Town

Who to contact during Clover Kids (3:30-5:00 p.m.)__________________________________________________________

2019-2020 4-H CLOVER KIDS

WHO: First through Third grade students TIME: 3:30 - 5:00 p.m. Once/month October-May

COST: $40.00 (includes educational materials and snack) $5.00 additional for Clover Kids t-shirt - please check on registration form!

PLEASE CHECK YOUR PREFERENCE:

____Remsen, 1st Thursday (When Thurs. class is filled, another class will be offered on 2nd Monday)

____Hinton, 1st Tuesday (When 1st Tues. class is filled, another class will be offered on 2nd Tues)

____Franklin, 2nd Tuesday ____Akron-Westfield, 1st Tuesday

____Clark, 1st Tuesday ____Gehlen Catholic, 1st Wednesday

____Kingsley-Pierson, 1st Monday ____Kluckhohn, 2nd Thursday

Class size is limited! If another day is offered at your school, classes will be filled first come-first serve. Don’t delay—register now!

RELEASE INFORMATION - Beyond parents, these individuals are authorized to pick up my child from Clover Kids and can be contacted if my child gets sick or needs medical attention. (Note: If there are any changes to this information, please send written notification of who they will be leaving with.)

Person to Contact First Backup Contact (Relative or Friend)

Name ________________________________ Name ________________________________

Relation to Participant ___________________ Relation to Participant ___________________

Daytime Phone ________________________ Daytime Phone _________________________

• Participate in hands-on STEM activities

• Have Fun!

• Develop 21st Century skills

• Meet new friends

HEALTH INFORMATION (Please Print)

Does the child have any of the following conditions or a history of any of the following conditions? (Check all that apply.)

Asthma Bronchitis Fainting Spells

Diabetes Ear Infections Heart or cardio-vascular problems/disease

Convulsions/seizure Hay Fever Chronic bone, muscle or joint injuries

Migraine headaches ADHD/ADD

Emotional Concerns: (Please list)___________________________

Other condition(s): (Please list)_______________________________

Allergies or reactions: (Check all that apply.)

Aspirin Penicillin Dairy Gluten Peanuts

Insect bites or stings Ivy/oak/sumac toxins Other (list) ___________________________

Is your child currently on any prescribed or over-the counter medication? (If so, please record the condition/ailment, name of medication, dosage, time(s) of day, prescribing physician.)

BEHAVIOR EXPECTATIONS OF THE PARTICIPANT

I understand that the following individual behaviors make group activities difficult and I will be asked to pick up my child from Clover Kids if there is a problem. Physical Harm, Unsafe Behavior, Inappropriate Language, Illness, Refusal to follow rules, Leaving the group without permission

_________initial __________date I understand that my child must be healthy and reasonably fit in order to safely participate in 4-H recreation activities and that I will inform the program leader(s) of any medication, ailment, condition, or injury that may affect his/her ability to participate safely.

MEDICAL EMERGENCY PARENTAL PERMISSION* The health history for my child is correct and complete to my knowledge. If an injury or other medical condition occurs or arises, I hereby give permis-sion to the ISU Extension staff or volunteer to provide routine first aid and seek emergency treatment including x-rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing or insurance purposes. I understand that I am financially responsible for charges and hereby guarantee full payment to the attending physicians or health care unit. In the event of an emergency where I cannot decide for my child, I give permission to the physician/hospital selected by the ISU Extension staff or volunteer to secure and administer treatment for my child, including hospi-talization. (*If you cannot sign this section of the form for any reason, contact the County Extension Director regarding a legal waiver in order to attend

and participate.) _________initial __________date

PUBLICITY/IMAGE/VOICE PERMISSION

_________Yes, pictures of my child may be used for publicity, news articles, on the county Extension and Clover Kid Facebook page-individual names will not be published. __________No, do not use pictures of my child.

4-H ASSUMPTION OF RISK AND RELEASE OF LIABILITY (Please read carefully.)

I give permission for __________________________ to participate in the 4-H program. I understand that 4-H project activities/events may involve certain risks of physical activity and possible injury and that Iowa State University and its 4-H program will provide each participant with reasonable care, but that ISU cannot guarantee that my child will remain free of injury. In addition, some 4-H projects including but not limited to: shooting sports, horse or livestock projects, water activities, and other sporting activities have a higher degree of risk. I nonetheless wish to have my child participate in the 4-H program and ASSUME the RISK of participating. I agree to RELEASE from LIABILITY, INDEMNIFY and HOLD HARMLESS the State of Iowa, the Board of Regents of the State of Iowa, ISU and ISU Extension and their officers, employees and agents (hereinafter the RELEASEES) from any and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabili-ties that occur as a result of my child’s participation in the 4-H program. This release, however, is not intended to release the above-mentioned RE-LEASEES from liability arising out of their sole negligence.

Parent or Guardian Signature _____________________________ Date __________________________

RETURN REGISTRATION FORM AND PAYMENT BY SEPTEMBER 20, 2019 TO:

ISU EXTENSION AND OUTREACH - PLYMOUTH COUNTY

251 12TH St SE, Le Mars Iowa 51031

A confirmation postcard with specific dates will be sent after registration is received.

Contact: Jodi Fisher, Clover Kids Coordinator, 712.546.7835, jlfisher@iastate.edu

Amount enclosed per child: _____$40.00 _____$5.00 for a Clover Kids t-shirt size-Youth (circle one if ordering): S M LG

I would be willing to be a helper for the Clover Kids group ______ YES ______ NO

I would be willing to be a Clover Kids leader: ______ YES ______NO