Ohio Envirothon Registration Form 2001
Area II & Ohio Envirothon Registration Form April 22, 2015 Kent State Geauga Campus Please type or neatly print _______________ County Team Team Name:________________________________________________________ School Address:________________________________ Phone: _______________ City: ________________________ County: _________________ Zip: __________ Name Sex Grade Level Team Captain: ________________________________ Team Member:________________________________ Team Member:________________________________ Team Member:________________________________ Team Member:________________________________ Alternate: _________________________________ Alternate: _________________________________ Alternate: _________________________________ Alternate: _________________________________ Alternate: _________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Advisor 1: _______________________________ M/F Summer address:_______________________________ Cell Phone:___________ E-mail address: _______________________________________ Option during testing: Take Test_____ or Participate in Geauga Park District Observatory Park Planetarium Program_____(please mark one) Advisor 2: ________________________________ M / F Summer address:________________________________ Cell Phone:___________ E-mail address: ______________________________________ Option during testing: Take Test_____ or Participate in Geauga Park District Observatory Park Planetarium Program_____(please mark one) NOTES: Only registered team members or alternates with signed release forms may participate in the Area or Ohio Envirothon. All teams must be registered by March 27th 2015. This is a FIRM deadline. Mail, fax, scan & e-mail all accepted. Alternate team members must be pre-registered, but may attend the Envirothon ONLY if substituting for a registered team member who is unable to participate. All team members, alternates and advisors must submit a release form with registration. *Note medical or dietary restrictions on back --- or any other additional information we should beware of. Please note any mobility or medical issues, or dietary restrictions. We will try to accommodate these as much as possible. Name Comments ___________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ ___________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ ___________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ ___________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Area and Ohio Envirothon Release Form This form is to be completed by each student’s parent/guardian and returned to Geauga SWCD. This form must also be completed and signed by advisors, staff persons and guests and returned to the Geauga SWCD. Attendee’s Full Name (please print)_____________________________________________________________ Home Address______________________________________________________________________________ Street address, City, State, Zip Code Home Phone ( )_________________________ Parent Work Phone ( )__________________________ Emergency Contact_______________________________________ Phone ( )________________________ Relationship to Attendee______________________________________________________________________ Medical Insurance Provider____________________________ Policy #________________________________ Allergies (food, medication, insects, etc.)_________________________________________________________ Medical Conditions (asthma, diabetes, etc.)_______________________________________________________ Medical Equipment Used (Epi-pen, inhaler, etc.)__________________________________________________ Please bring any needed medical supplies with you to the testing stations. Medications Currently Being Taken_____________________________________________________________ I understand the Ohio Envirothon may be strenuous and adverse weather conditions may occur. Nevertheless, I assume the risk involved. In the event of an accident, I authorize the Ohio Envirothon to provide emergency medical treatment for me during this event. I have been assured that all reasonable care will be taken to prevent incident: therefore, I will not hold Ohio Envirothon, the Ohio Federation of Soil and Water Conservation Districts, or the host site liable should an accident occur. I also give my consent to the use of any photographs or videos taken of me by officials of the Envirothon or their representatives to be used for promotional and/or editorial purposes only. Signature of Participant________________________________________ Date__________________________ I (please print)_____________________ (parent/guardian) give permission for my child ___________________ (name) to participate in the Area and/or Ohio Envirothon. Signature of Parent/Guardian_____________________________________ Date________________________ Relationship to Participant____________________________________________________________________ Revised 8/2010
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