Welcome to 4H Jefferson County

Adult Enrollment Form

Please check one: _____ New _____ Returning Please check one: _____ Female _____ Male

Please check one: ____General/Org. Ldr. ____Project Ldr. ____Activity Ldr. ____Resource Ldr. ____ Member

Please check one or more: _____ Direct Volunteer ____ Indirect Volunteer ____ Middle Manager

Adult's Last Name ____________________________________ First Name ____________________________ M.I. __________

Address: ________________________________________ City: ___________________________ Zip: __________________

Home #: _____________________________________ Work #: ____________________________________ Year in 4-H ______

Adult's Email Address: ______________________________________________________________________________________

Please check one for your residence: ____ Rural ____ Farm

Ethnic: ____Hispanic ____Not Hispanic

Check all that apply:

Race: ____White ____Black ____Am. Indian/Alaskan ____Asian ____Hispanic

Group Name: __________________________ Main Project: ____________________ Group Leader: ______________________

Please list the project names and codes for the above adult leader. (See the four digit project codes on back of this form.)

PROJECT CODE PROJECT NAME PROJECT YEAR

_______________ _______________________________________________________________ __________________

_______________ _______________________________________________________________ __________________
_______________ _______________________________________________________________ __________________
_______________ _______________________________________________________________ __________________
_______________ _______________________________________________________________ __________________

Adult's Signature: ________________________________________________________________ Date: _____________________

Leader Signature (if different person than above adult): ___________________________________ Date: ____________________

WSU Jefferson County Extension, 201 W. Patison, Port Hadlock, WA 98339 360-379-5610
 Welcome to 4H Jefferson County
Adult Photo Model Release Form
I hereby grant permission to be photographed, voluntarily and without compensation, by Washington State University and 4-H
Jefferson County, understanding that the same is intended for publication by print media, newspaper, website, television, video, or
motion picture.

I additionally consent to the use of my name in connection with the publication by print media, newspaper, television, website,
video, or motion pictures of photographs taken of me.

Adult's Signature: ________________________________________________________ Date: _______________________

Witness: ________________________________________________________________ Date: ______________________

Adult Medical Emergency Form

This information will be referred to in the event that you experience a health-related emergency during 4-H activities.

Adult's Name: _____________________________________________ Home Phone ______________________________

Doctor's Name : ______________________________________________ Phone #: _______________________________

Medical Insurance Carrier: __________________________________________ Phone #: ___________________________

Policy #: ___________________________________________ Clinic: _________________________________________

Do you have any health-related problems that the 4-H organization should be aware of? _____ Yes _____ No

If yes, please explain: ________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Waiver: In consideration of your accepting my entry into 4-H, I hereby for myself, my child or children when applicable, my
heirs, executors and administrators waive and release any and all rights and claims for damages I might have against Jefferson
County, WSU Extension, and Jefferson County Fair through 4-H and its representatives, volunteers, successors or assignees and
the Quilcene, Brinnon, Chimacum, or Port Townsend School Districts for any and all injuries suffered by myself while going to,
participating in, or returning from this activity. I have read this statement and my signature below verifies my acceptance of these
conditions.

Adult Signature: ________________________________________________ Date: __________________________

WSU Jefferson County Extension, 201 W. Patison, Port Hadlock, WA 98339 360-379-5610