Name:______________________________________ Phone Number:______________________________ Age:______Male/Female:______Birthday:______ 1st class____________2nd Class_____________ Address:___________________________________ 4-H Club:_________________Years in 4-H:____ *Please include a list of emergency contacts including phone number and relationship with your registration form. In order to place photos in the newspaper, we must have a signed media release on each camper. I herebygive my consent for the image and likeness of _______________________ to be videotaped audio taped, or photographed for the following uses: Education/Instructional media and Newsworthy media documentation. This waiver includesusage of this media in any way deemed appropriate, which may include electronic and photographic reproductions thereof for the production of educational, instructional promotional, or institutional, advancement materials, which support the educational and outreach activities of West Virginia University. I hereby waive any right I may have to inspect or approve any use of this electronic media and/or photographs and I release WVU and its component parts from all liability, which could result from its use. ___________________________ ___________________________ Signature of Camper Signature of Guardian/Date Programs and activities offered by the West Virginia University Extension Service are available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political believes, sexual orientation, national origin, and marital or family status.