Even though Kansas 4-H is not bound by HIPPA (Health Insurance Portability and Accountability Act), 4-H leaders should make all reasonable efforts to see that: a) only authorized individuals have access to health, medication, and related information and b) Kansas 4-H Participation Forms and related health information is securely filed to prevent casual access. Copies of the Kansas 4-H Participation Forms may be made and distributed to Club and Project Leaders and chaperones for risk management purposes. Club Leaders, Project Leaders and chaperones are encouraged to keep Kansas 4-H Participation Forms in a notebook or folder to reduce risk of information being distributed. Notebook or folder should be available at all 4-H events - local, state and national. The Kansas 4-H Participation Form may be required with 4-H event registration and must be mailed to the State 4-H Office.

Rock Springs 4-H Center requires a copy of the Kansas 4-H Participation from all participants for each event conducted. The Kansas 4-H Participation will remain on file at Rock Springs.

Sections of the Kansas 4-H Participation Form include: participant’s demographic and contact information; emergency contacts' phone numbers (indicate Home, Work, or Cell); insurance information; health history and over-the-counter medication approval; releases for publicity and evaluations; the Kansas 4-H Code of Conduct (based on the CHARACTER COUNTS! Six Pillars of Character) which requires signatures from both youth and adult participants; and a signature area with releases required for participation in all Kansas 4-H events. This form does NOT need to be notarized.

Since the Kansas 4-H Participation Form is designed to be collected only once each year, it is the responsibility of participants or parents to accurately complete the form and make updates, changes, or replace their forms as necessary. Participants should be encouraged to review and update their forms before each major event or activity with special attention given to current medications, illnesses, or injuries.

Participants or parents are responsible for completing the Kansas 4-H Participation Form in its entirety. The K-State University Attorney's Office has indicated that "failure to complete this form in its entirety will result in the person being ineligible to participate in 4 H activities". If a line or section is not applicable it must be marked with "N/A" or some other indication that the participant did not skip or forget to provide the information. For example, if the family has no health insurance, a company name and policy number would not be applicable.

We have attempted to develop this as carefully and thoroughly as possible, but there is always room "to make the best better." So, as you work with this new form, please let the state 4-H office know if there is anything that can be improved in future revisions.

Revised Kansas 4-H Participation Form
Based on feedback from agents and usage over three years, several refinements were made to the Kansas 4-H Participation Form (Publication Number MG35) last January.  It has been available on the web in both PDF and Microsoft Word Form versions since January, 2008. Either version of the Kansas 4-H Participation Form has been accepted for state 4-H events occurring prior to October 1, 2008.  After that date, in conjunction with re-enrollment, all participants must submit the new 2008 version of the form.

Specific changes to the revised form include:

• Added a request to use blue or black ink to facilitate copying

• Re-organized participant contact information section

• Clarified emergency contact information: lists two contacts with two phone numbers each. Users can indicated Home, Work, or Cell numbers.

• Removed references to “Survey” in Evaluation Release section

• Revised the code of conduct to reflect the CHARACTER COUNTS language and concepts

• Broadened code of conduct to encompass all 4-H participation; not just at events

• Added adult statement which incorporates both the code of conduct as well as the “Kansas 4-H Volunteer Code of Ethics required for all adult volunteers through the Volunteer Information Profile

• Reduced the number of signatures and dates required in the verification section from three down to one

• Modified second paragraph in the verification section by adding “Kansas 4-H Volunteer Code of Ethics (for adult participants)”

If you wish to provide the form through your county web site, please link to the PDF version on the KSRE Publications Library at http://www.oznet.ksu.edu/library/4h_y2/mg35.pdf.  You may also link directly to a Microsoft Word Form version at: http://www.Kansas4-H.org/Forms/Participation/MG35Kansas4-HParticipationForm.doc  The Microsoft Word Forms version is set up to preserve the layout and formatting of the document, yet allows participants to save and edit their information as needed.  By linking directly to these forms, you save server space and remain linked to the most current form regardless of future edits.