DACC Career Exploration Academy

NM County

Name of School

Grade

Age

Mailing Address

Gender

Ethnicity/Race

Adult T-Shirt Size

Please list any dietary restrictions:

Are you currently involved in 4-H?

How many years have you been involved in 4-H?

If not, are you interested in learning more about 4-H?

Parent/Guardian Emergency Contact Information:

Parent Name (required)

Parent Cell Phone Number (required)

Parent Work Phone Number

Parent Email Address

New Mexico 4-H Media Release

Participants in NMSU, Cooperative Extension Service, 4-H Youth Development Program events are sometimes photographed and videotaped for use in NMSU promotional and educational materials.

I authorize New Mexico State University to record and photograph the image and/or voice of my child for use by New Mexico State University or its assignees in research, educational, and promotional programs.

I understand and agree that these audio, video, film, digital, and/or print images may be edited, duplicated, distributed, reproduced, broadcast, used in electronic and web media, and/or reformatted in any form and manner without payment of fees, in perpetuity.

If you DO NOT consent to this media release, please check the box below and sign and date within the subsequent box.

Sign and Date