Benton County Progressive Agriculture Safety Day
2022 Release and Consent Form II
1) I give my permission for the child listed below to attend the Progressive Agriculture Safety Day®.  I understand that one of the purposes of the Progressive Agriculture Safety Day® is to teach participants to stay  safe around farm sites, farm equipment, and farm animals.  During the Safety Day, safety barriers will be in place, safety rules will be enforced, and participants will be closely supervised by Safety Day instructors and group leaders. However, I acknowledge that there is the possibility of accidents. I release the coordinators,  instructors, volunteers, sponsors, the Progressive Agriculture Foundation, and the Progressive Agriculture Safety Day® program from all claims, in the event of injury to my child, unless the injury is the result of gross negligence or willful misconduct on the part of these parties.

2) First aid will be available at the Safety Day and medical and/or hospital care will be provided in case of serious illness or injury. I understand that if serious illness or injury occurs the emergency contact(s)  listed below will be notified. If it is impossible to reach the emergency contact(s), I give permission for emergency treatment as recommended by the attending physician.

3) I give my permission for photographs, audio, and video to be taken of my child while engaged in Safety Day activities and for these images to be used to promote safety in the media, social media, on websites, and in promotional materials.

4) I understand that my child might be asked to complete a written knowledge test before and after the Safety Day to help evaluate the effectiveness of the Progressive Agriculture Safety Day® program.  Participation is voluntary, and my child may choose not to participate. I give permission for my child to participate in these evaluations.
Sign in to Google to save your progress. Learn more
Email *
Email *
First and Last Name of Parent/Guardian *
First and Last Name of Participant *
Choose Participant's Age *
Participant's Grade in School *
Participant is *
Street Address *
City *
State *
Zip Code *
Emergency Contact 1 *
First and Last Name
Emergency Contact Phone Number 1 *
Emergency Contact 2 *
First and Last Name
Emergency Contact Phone Number 2 *
I have read and agree to the above information. (With Exceptions, see boxes checked) *
Note: If you give permission for all or part of items 2, 3, or 4 simply check the boxes you DO agree with, leave blank the boxes you do NOT agree to. However, if you do not agree to item 1, your child cannot attend the safety day.
I have read and agree to the above information. *
Required
Parent/Guardian Signature *
By typing your first & last name in the box below you agree that you have read and agree to the above information.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Vinton-Shellsburg Community School District. Report Abuse