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					                                         Youth Leadership Conference Registration Application
                                                          June 11-13, 2010


                    Delegate                      Chaperon                            County

NName                                                                                   Primary Email Address

  T-Shirt Size: (Circle one)
                                                                                        Parent’s Email Address
  Small         Medium         Large   X-Large        XX-Large
  Address                                                                      City                                                Zip


  Sex                  DOB                                                     Phone



                                       Health Statement and Parent's Release (Delegates Only)
*This information will be kept confidential.

I hereby grant permission for my child, named above, to participate in the Alfa Farmers Youth Leadership Conference. I grant
permission to him/her to receive any medical attention deemed necessary by the adult chaperons for injury or sickness, which occurs
during this event and will be responsible for payment of all medical costs. Furthermore, I will not hold liable the Alfa Farmers
Federation, the Alabama 4-H Foundation, or employees from either organization engaged in this activity.

Parent's Signature                                                                              Date

Address                                                                               Home Phone

If any of the conditions listed below apply to the delegate entering this event, answer "yes" in the blank provided. If the answer is "yes"
to any of the following, give details in the space provided at the bottom of this page, indicating diagnosis, date of illness or injury, name
of hospital, length of hospitalization, name of doctor, etc.
                                                                                                                                                      Answer
                                                                                                                                                    Yes or No
1. Nervous or mental: symptoms such as epilepsy, breakdown, convulsion, loss of
     consciousness, dizziness, paralysis ................................................................................................
2. Lung disease: asthma, blood spitting, persistent cough, tuberculosis ..............................................
3. Disease of heart or blood vessels: increased or abnormal blood pressure .....................................
4. Pain in chest or shortness of breath ................................................................................................
5. Stomach or intestinal troubles: ulcers, gall bladder or liver disorder, jaundice, hernia......................
6. Arthritis, rheumatic fever, goiter, diabetes, kidney or bladder disease ..............................................
7. Hay fever or allergy...........................................................................................................................
8. Any surgical operation, accidents, or injuries....................................................................................
9. Impaired sight or hearing, chronic ear infections ..............................................................................
10. Any infectious disease or contact with infectious disease in week prior to this event .......................
11. Skin diseases....................................................................................................................................
12. Allergy to medicines or foods ............................................................................................................
13. Currently taking medicine .................................................................................................................
14. Under care of physician ....................................................................................................................
15. Requires a restricted diet ..................................................................................................................

If the answer is "yes" to any of the above, give details here:

				
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