Jersey County 4-H Show Clinic RSVP
PLEASE REGISTER ALL STUDENTS SEPARATELY  

Event Address: Jersey County Fairgrounds - 100 W Fairground Ave., Jerseyville, IL 62052

Contact us by visiting our Facebook page at https://www.facebook.com/prairietownfeed or by calling us at (618) 818-5736

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Can you attend? *
What is the name of student attendee?  *
What grade are you in?  *
What county are you from? *
1st Species of Interest (What is the species that interests you THE MOST) *
Required
2nd Species of Interest 
If you are a High School Student, you are welcome to participate, but you are also welcome to be a volunteer helper for 4-H community service hours.

Which would you like us to sign you up as?
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One thing you'd like to learn at the show clinic *
Favorite Pizza Flavor  *
Does the student have any allergies? If yes, please list them below.
Would your parent like a text reminder? 
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If Yes to the above question, please provide a phone number...
How did you hear about this event?
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Emergency Contact: Please include name, phone number, and address

 *
I hereby release Purina Animal Nutrition and Prairietown Feed Service from any and all liabilities that may occur from injury or loss during the Jersey County Show Clinic on May 18, 2024. *

Photo/Media Release: I grant the University of Illinois Extension 4-H Youth Program, Purina Animal Nutrition, and Prairietown Feed Service irrevocable permission to record and/or disclose my child's identity, image, and voice arising out of documenting 4-H youth programs. and to use, reproduce and distribute such in whole or in part in video and/or sound recordings, films, photographs, transparencies, webpages, social media, local news media or any other media for any purpose on behalf of the University of and Extension without compensations to me and without any right for me to inspect or approve of the finished photograph, video, or audio recordings or other recordings.

Mark YES or No

 *

Accommodation Statement: Does participant need reasonable accommodation for this program? If yes, please list below or call your local Extension office. 

 *

Civil Rights Compliance – Participant Info: As part of our commitment to providing equal opportunities in our programming, University of Illinois Extension is required to collect and report overall statistics about the race, ethnicity, and gender of program participants. Your response are voluntary and appreciated.

Gender 

Ethnicity
Race
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