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:
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Alternate:
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Alternate:
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Alternate:
_________________________________
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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
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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