2024 R6 DD Reg form

Region 6 Discovery Days

Discovery Days will be held at the Dorchester Agriculture Hall on July 6, 2024! If you have any questions please email opportunities@4-hontario.ca
Participant Information
Name*

First NameLast Name
Preferred Name
Birthdate*

MonthDayYear
I identify my gender as *.
The pronouns I use are * / * .
Participant Phone Number*
Please enter a valid phone number.
Participant Email*
example@example.com
Parent/ Guardian Email*
example@example.com
Parent/ Guardian Phone Number
Please enter a valid phone number.
How are you connected to 4-H?*
4-H Association
4-H Ontario Participant Number
Geo status *
T-Shirt Size*
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
How did you find out about this experience?*
Please specify how you found out about this experience

Health Information

4-H Ontario is dedicated to providing an experience that honours each person's safety and abilities. Please complete this section in its entirety so that 4-H Ontario may provide you with the best experience possible while you are at Discovery days.
Allergies (Medication, Food & Environmental)

Please describe any allergies you have in the appropriate box below, including:
- What you are allergic to
- Reactions
- Severity of allergy/reaction
- Treatment - if you require use of an epi-pen, please note that in the medications field.
If you do not have any, please put n/a in the comments box.

Please note we provide a pizza lunch and snacks at camp, so if this information is imporant so we can accomdate and special dietray resicritons
Medical Allergies:*
Food Allergies:*
Environmental Allergies:*
Dietary Needs*

Gluten-freeHalalLactose-freeVeganVegetarianNo dietary needsOther
Please provide any other information and details related to your dietary needs
Medications

Please list all of the medications you are currently taking. In the event of an emergency where you are unable to speak for yourself, medical personnel need to know what medications you are taking.

If medication will need to be used during the Discovery Day experience, please bring it in its original bottle, with your name on it.

Please include if you have an epi-pen for an allergy noted above.

If you do not have any medications, please put n/a.
Medications:*
Is there any other information (medical, behaviourial, or other) that 4-H Ontario should be aware of? Particularly anything that may prevent you from fully participating in this experience or any supports that may assist us in providing a full experience ? Please describe.
Emergency Contact Information

4-H Ontario staff will contact the emergency contact(s) provided below in the case of an emergency with a participant. Please ensure the contact details provided below are accurate and will be reachable during the time of this experience.
Emergency Contact Name (Primary)*

First NameLast Name
Emerg Contact Relationship (Primary) *
Emergency Contact Email (Primary)
example@example.com
Emerg Contact Phone # (Primary)*
Please enter a valid phone number.
Emergency Contact (Secondary)

First NameLast Name
Emerg Contact Relationship (Second)
Emergency Contact Phone # (Second)
Please enter a valid phone number.
Emergency Contact Email (Secondary)
example@example.com
Physicians Name*
Physicians Phone Number
Please enter a valid phone number.

Legalese

Please read and acknowledge the information below. A signature is required at the bottom of this form.
Consent to Participate in 4-H Ontario Activities

For participants if 18 years of age or older, OR parents/guardians of participants under 18 years old: I, the undersigned hereby:
- Consent to the collection of personal information set out above, including the personal health information (collectively the ‘personal information’) for the purposes specified.
- Represents to 4-H Ontario, the Ontario 4-H Council and Ontario 4-H Foundation (together 4-H) that the personal information is true, complete, accurate and correct.
- Releases and indemnifies 4-H from any claim arising as a result of any untruth, incompleteness, inaccuracy or incorrectness of the personal information.
- Represents that the participant is in good health and is able to participate in all activities of 4-H except as noted in the personal information; and
- Agrees to notify 4-H if the participant is exposed to an infectious disease at any time during the three weeks prior to the commencement of the activity in which the participant will participate.
Consent to Participate*

I consent
4-H Ontario Media Release

While participating in 4-H activities, photos and videos of participants will be taken. These photos are typically used to record memories and promote 4-H. Please indicate below your consent to the use and reproduction by 4-H Ontario (representing the Ontario 4-H Council and Ontario 4-H Foundation) of any and all photographs, video recordings and audio recordings taken of myself or my child for the use on 4-H websites, in print and other media for the purposes of promotion, illustration, advertising or publication and without compensation. All such photographs, video recordings, audio recordings and all recorded media, prints and created media from the content shall constitute the property of 4-H. In addition, the undersigned hereby consents to authorize the publication of the name of the participant. Important Reminder: Photos, images and media may appear in electronic form on the Internet or in other publications outside of 4-H Ontario’s control.
4-H Ontario Media Release*

I consent to the media releaseI do not consent to the media releaseI consent, with exceptions*
Media Release exceptions
4-H Code of Conduct
Please review the Code of Conduct
I have reviewed the Code of Conduct and I agree that myself and/or the youth participant (under the age of 18 years) in my care will abide by this Code. I understand that any breach of the 4-H Ontario Code of Conduct could be cause for dismissal from the activity and/or from the 4-H Ontario program.

I consent
4-H Inclusion Statement
Please review the 4-H Inclusion Statement below:
I have reviewed the 4-H Inclusion Statement and I agree to abide by this statement.*

I consent
Signature (Participant if 18+ years of age) or Parent/Guardian (of participant under 18)

Clear

4-H Ontario Camp & Conference Registration Policies

Prior to submitting your registration for this experience, please review 4-H Ontario's Camp, Conference and Competition Registration Policies.

You may find the most current policies by following these steps:
- Click: Link to 4-H Ontario Policies
- In the search bar, located in the middle of your screen under Full Policy Manual, search 4.2.1. This will open a PDF document in your web browser.
- Go to O-M-13 - 4-H Ontario Camp, Conference and Competition Registration Policies on page 7.
- Here you will find the policies surrounding Cancellations & Refunds.
I have reviewed and understand the 4-H Ontario Camp & Conference Registration policies, including cancellations and refunds.*

Yes, I have reviewed and understand these policies.
Tell a Friend!

Don't let your friends miss out on this great opportunity! Fill in their name and email address to to remind them that a Discovery Day is happening in their area! *Refer a friend and be entered to win a prize!*
Friend's Name
Friend's Email
example@example.com
Payment
Name of person submitting payment for the participant (i.e. parent/guardian)*

First NameLast Name
My Products
prevnext( X )
DD Region 6 Camp RegistrationThis fee covers your experience at Discovery Days, including Lunch, activities and supplies.
$35.00CAD

Total

$0.00CAD

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Region 6 Discovery Days

Participant Information

Health Information

Allergies (Medication, Food & Environmental)

Medications

Emergency Contact Information

Legalese

Consent to Participate in 4-H Ontario Activities

4-H Ontario Media Release

4-H Code of Conduct

4-H Inclusion Statement

Tell a Friend!

Payment