2016 NORTH AMERICAN INVITATION 4-H DAIRY QUIZ BOWL CONTEST ENTRY
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State:
State Dairy Contact Person: Telephone:
Email Address:
Street (Mailing) Address:
City State Zip code
State 4-H Program Leader:
Name:
Email address:
(1) I verify that participants, employees, coaches, and volunteers from my LGU have a signed medical form with permission for medical treatment, a photo release and Code of Conduct, Medical/accident Insurance and Liability Coverage from the time of departure from my state until return. I also verify that my state has a Risk Management Plan for participants, and all coaches and chaperones accompanying the group have been background checked, screened and accepted as a volunteer by my LGU. I understand that employees, volunteers on management teams and/or individuals who work for the management team from my university will be functioning under the operating procedures, practices and scope of duties with oversight and risks associated with my LGU.
(2) I certify that the above contestants (and any substitutes) meet the eligibility criteria as outlined in the 2016 NAILE Invitational 4-H Dairy Quiz Bowl Rules as posted at https://afs.ca.uky.edu/dairy/north-american-dairy-quiz-bowl
______
State 4-H Program Leader Original Signature Date
______
State Dairy Team/Event Coordinator Original Signature Date
2016 NORTH AMERICAN INVITATION 4-H DAIRY QUIZ BOWL CONTEST ENTRY
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State: ______
Participants
Team Members / Complete Address / Birthdate / Special Dietary Needs based on Medical Condition (Yes* or No)1.
2.
3.
4.
Alternate(s)
1.
2.
Coaches / Complete Address / Cell Phone # / Email address / Special Dietary Needs based on Medical Condition (Yes* or No)
1.
2.
* If a medical condition exists that impacts meals, please provide a detailed email request at time of entry outlining condition so that caterer can be notified in advance.
Entry Fees:
Registration Fee (includes five (5) lunches and five (5) banquet tickets - = $ 300.00
(all tickets are non-transferable to another team)
Late Registration Fee ($50) = $______
(Late fee must be paid if electronic entry with completed team members is received after Mon., Sept. 26, 2016 at 5 PM EDT and/or signed form and check is postmarked after Sept. 26th. Late fee must be received by Wed., Oct 12th or team will forfeit their chances to complete
Extra tickets are available at time of entry. (No additional charges for Pizza Party)
Number extra lunch tickets x $14.00 each (actual cost) = $ ______
Number extra banquet tickets x $20.00 each (actual cost) = $ ______
Total entry fees = $ ______
Please make your entry check payable to: Kentucky 4-H Foundation - NAILE Dairy Quiz Bowl (Sorry, we cannot accept credit card payment. Fees are non-refundable.)
Return this completed entry by Monday, September 26th by both USPS mail (check and original signature) and electronically as a MS Word document (not as PDF file) to:
Donna M. Amaral-Phillips, 414 W. P. Garrigus Building,
University of Kentucky, Lexington, KY 40546-0215
Ph: (859) 257-7542
Email:
Confirmation information will be sent electronically to both state contacts and coaches. Check the following website: https://afs.ca.uky.edu/dairy/north-american-dairy-quiz-bowl for updates.