Clover Kids Release Form

Clover Kids Release Form

All Clover Kids participants must fill out and turn in the enclosed Iowa 4-H Medical Information/Release Form prior to the first meeting. The leader will have this form at all Clover Kids activities to ensure each member is appropriately taken care of in any situation that may arise.

If you have any questions please contact the Extension Office at 563-547-3001. Office hours are Monday-Friday 8:00 AM- Noon and 12:30 - 4:30 PM.

Information we should know about your child.

Please check appropriate response:

I will pick my child up at the end of the program.

Igivepermissionformychildtowalk/ridebikehomeaftertheprogram.

My child may be pickedupby2016-2017

Parents: I am willing to help and the following month(s) work best:

NovDecFebMarchApril

Howard County Clover Kids

Howard CountyCloverKidsRegistrationForm—Elma

To enroll in the Howard County Clover Kids program, complete both sides of this form and the Iowa 4-H Medical Information/Release Form, enclose the $12 fee (plus optional $3 for a t-shirt), and return to the Howard County Extension Office by October 21, 2016. Class size is limited.

Where: Cost:

Age:

St. Paul’s Maple Leaf Lutheran Church 13431 Howard Ave, Elma, IA 50628

$12 - Registration

$3 -Clover Kids T-shirt K-3rdgrade

Saturday(Elma)After School

NameofChild CurrentGradeAge Address CityZip

Parent’sName

Howard County Clover Kids is a program sponsored by Howard County Extension to begin teaching the importance of the world around us to students in K-3 grades. Each session will offer a variety of experiments, activities, crafts, and games. We will explore a variety of topics throughout the year in the following areas STEM (Science, Technology, Engineering, and Math), Healthy Living, Citizenship and Leadership, and Communication and Arts.

Also available this year is are after school meetings in Riceville and Cresco. Meetings will be held from 3:15 - 5:15 p.m. at Riceville School on 2nd Monday and Notre Dame Church on 1st Tuesday. Meeting will be held

Home PhoneWork Phone E-mailAddress School Sex:(circleone) Residence: (circleone)

Male FemaleFarmTown

at Crestwood School from 3:30 - 5:30 p.m. on the 1st Thursday. They are held once a month from November to April (skip January).

Please fill out the registration form and return it to the Howard County Extension Office by October 21, 2016 along with the enclosed Iowa 4-H Medical Information and Release Form and registration fee. Additional forms

Ethnicity (circle one)

WhiteBlackHispanic

AsianAmerican Indian/Alaskan

Return by Oct. 21, 2016 to:

ISU Extension - Howard County

T-Shirt: □ Yes □ No

Youth Sizes Small 6-8

Medium 10-12

Large 14-16

can be picked up at the Extension Office.

If you have any questions give us a call at

132 1st Ave W Cresco, IA53136

Makecheckspayableto:

Howard County Extension

Adult

563-547-3001.**PLEASE COMPLETE BACK SIDE OFFORM**

Extension programs are available to all without regard to race, color, national origin, religion, sex, age or disability. The fees for service will be used to offset direct expenses and to support the County 4-H and Youth Extension Program.