<p> HAMILTON, HARDIN, HUMBOLDT, WEBSTER, WRIGHT 2017 OMAHA ZOO TRIP Registration Form </p><p>(Please circle one) COUNTY: Hamilton Hardin Humboldt Webster Wright</p><p>PARTICIPANTS NAME: ______First Last ADDRESS: ______Street or Box City Zip</p><p>HOME PHONE_____/_____-______PARENT CELL PHONE _____/______-______</p><p>YOUTH CELL PHONE ____/_____-_____ Will youth have cell phone on trip? YES NO</p><p>Email: ______Grade in School ______</p><p>(Please Circle which apply) (MALE / FEMALE) (YOUTH / CHAPERONE) Special Needs: (Please circle) Yes/No Describe if yes: ______Have you attended this trip before? YES NO </p><p>Parent/ Guardians Signature ______</p><p>Omaha Zoo trip Code of Conduct read & signed by participant & parent/guardian Iowa 4-H Medical Information/ Release Form: ______On file with local Extension Office no changes needed. ______Changes (Please provide new information)</p><p>Transportation: (please circle which apply) Friday, April 7 Pick-up Site: Saturday, April 8 Drop-off Site: ____4:30pm Webster City –Country Kitchen Truck Stop ____5:30 pm Fort Dodge – same location </p><p>____5:00 pm Fort Dodge – Quality Inn (south of junction 169 & old ____6:00 pm Webster City – same location hwy 20) </p><p>Saturday noon meal will be pre-ordered sub. Please circle your selection from the following 5”sandwich on white bread: Turkey & Provolone Turkey & Cheddar Ham & Provolone Ham & Cheddar</p><p>Roast Beef & Provolone Roast Beef & Cheddar</p><p>The fees for service will be used to off-set direct expenses and to support the 4-H Youth Development County Extension Program.</p><p>Iowa State University Extension and Outreach does not discriminate on the basis of age, disability, ethnicity, gender identity, genetic information, marital status, Iowa State University Extension and Outreach does not discriminate on national origin, pregnancy, race, religion, sex, sexual orientation, socioeconomic status, or status as a U.S. veteran. (Not all prohibited bases apply to all the basis of age, disability, ethnicity, gender identity, genetic programs.) Inquiries regarding non-discrimination policies may be directed to Ross Wilburn, information,Diversity Officer, marital 2150 status, Beardshear national Hall,origin, 515 pregnancy, Morrill Road, race, Ames, religion, Iowa 50011, 515-294-1482, [email protected]. sex, sexual orientation, socioeconomic status, or status as a U.S. veteran. (Not all prohibited bases apply to all programs.) Inquiries regarding non-discrimination policies may be directed to Ross Wilburn, Diversity Officer, 2150 Beardshear Hall, 515 Morrill Road, Ames, Iowa 50011, 515-294-1482, [email protected]. OMAHA ZOO TRIP CODE OF CONDUCT You will make the 5 County Omaha Zoo Trip a success. </p><p>Expectations: It is expected that all persons taking part in any Extension sponsored youth and 4-H activity/trip will conduct themselves in a civil, law-abiding, responsible, cooperative and courteous manner throughout the entire trip/activity until returning home. </p><p>Some Specifics:  I understand cell phones will be turned off during activities and may be confiscated if used.  I understand I should use good judgment and understand that there will be consequences for the infractions and other behavior deemed unreasonable or inappropriate.  I understand it is important to follow the directions of the Trip Coordinator and Volunteer Chaperones at all times.  I understand that as a participant I have the responsibility to help make the activity a safe experience for everyone through my behavior and conduct.  I understand the danger of not following rules and directions and agree to follow them.  I understand all participants and chaperones will be treated with respect and attention.  I understand the need to observe pedestrian traffic regulations.  I understand the use of alcohol, tobacco, or illegal drugs is not permitted.  I understand bringing of knives (including pocket knives) or firearms is not permitted.  I understand all participants shall show respect for the property and facilities used during this event and assume financial responsibility for any damages they cause </p><p>Possible Consequences:  I understand that I could be separated from group  I understand that I will be required to write apologies to chaperones and other group members  I understand that I may be required to give oral apologies to county 4-H committees.  I understand that if I break this agreement or my conduct is not satisfactory to the trip staff or volunteers, that I may not be eligible to participate in future 4-H activities. </p><p>I have read the above statement regarding conduct expectations and agree to participate under these conditions. </p><p>Participant’s Signature: ______Date: ______</p><p>Parent/Guardian’s Signature: ______Date: ______</p><p>Iowa State University Extension and Outreach does not discriminate on the basis of age, disability, ethnicity, gender identity, genetic information, marital status, Iowa State University Extension and Outreach does not discriminate on national origin, pregnancy, race, religion, sex, sexual orientation, socioeconomic status, or status as a U.S. veteran. (Not all prohibited bases apply to all the basis of age, disability, ethnicity, gender identity, genetic programs.) Inquiries regarding non-discrimination policies may be directed to Ross Wilburn, information,Diversity Officer, marital 2150 status, Beardshear national Hall,origin, 515 pregnancy, Morrill Road, race, Ames, religion, Iowa 50011, 515-294-1482, [email protected]. sex, sexual orientation, socioeconomic status, or status as a U.S. veteran. (Not all prohibited bases apply to all programs.) Inquiries regarding non-discrimination policies may be directed to Ross Wilburn, Diversity Officer, 2150 Beardshear Hall, 515 Morrill Road, Ames, Iowa 50011, 515-294-1482, [email protected].</p>