Utah FFA Association – Dixie Junior Livestock Show

Code of Conduct/Permission Form/Medical Information

I ______from ______

(print/type student’s full name)(print/type name of CHAPTER)

promise to abide by the following rules. I understand that I may be sent home at the sole discretion of my advisor or the activity staff, at my own or my parent’s expense, for any infraction of these rules and I agree to pay for any damages caused by my actions.

  1. I will not hold the Utah FFA Association, its officers, and staff responsible for travel supervision or travel accidents during this activity.
  2. I will not be in a room with a person of the opposite sex without the door being propped fully open - this is applicable for travel and all other situations.
  3. I will not use or possess any form of illegal drugs, alcohol or tobacco.
  4. I will wear Official FFA dress as listed I the official FFA Manual during showing and all other specified times.
  5. I will at all times follow the FFA Code of Ethics as listed in the Official FFA Manual.
  6. I will attend all relevant activities associated with the event as assigned by leadership and be courteous and attentive to all speakers, presenters, judges, leaders, etc.
  7. I will follow the directions of all advisors, chaperones, and leadership.
  8. I will not use inappropriate language or gestures.
  9. I will be respectful of others property and will not damage any facilities or property. I will allow inspection of my area, room, and space for which I am responsible by my advisor, chaperones, leadership or activity staff.
  10. I agree that my photographic/film image may be taken and used by the Utah FFA Association/ 4-H/USU Staff at its sole discretion.

Signature of Student Participant: ______

Parent/Guardian: I have reviewed the above information and agree to these rules for my student and myself. I agree to accept financial responsibility for my student’s actions, including travel costs, if my student is sent home. I understand and acknowledge that the Utah FFA Association/4-H/USU, including all officers and staff are not responsible for supervision of my student while traveling to, participating in and traveling from this activity. Supervision of my student is through their local FFA Chapter Advisor or designated chaperone.

PRINTED name Parent/Guardian: ______

Signature Parent/Guardian: ______

Advisor: This student meets all school/district qualifications to attend the activity and has my approval to attend and participate. I agree to enforce the rules stated above.

Signature of Chapter Advisor: ______

Emergency and Medical Information

______

Emergency Contact NameEmergency Contact Name

______

PhonePhone

______

Address, City, State, ZIPAddress, City, State, ZIP

______

Family Physician Physician Phone Date of last tetanus shot

My child has the following allergies, medical concerns or special needs (please include any food or drug allergies.):

______

______

In the event of an emergency, I hereby give permission to the FFA/4-H staff to request emergency services for my child, which may include transportation to a medical facility, and in the event that none of the contacts listed above can be reached. I also give permission to the physician to hospitalize and provide proper necessary treatment to my child.

______

Signature Parent/GuardianDate