2011 Gouverneur – St. Lawrence County Fair

4-H/FFA Overnight Request Form

 

NOTE:  This completed form, along with a completed Health Form, should be turned in to the Cornell Cooperative Extension Office or FFA teacher by Monday, July 18, 2011.

 

Name:_____________________________

 

Address:___________________________

 

                ____________________________

 

Telephone Number: __________________ 4-H Club/FFA Chapter__________________

 

I request permission to stay overnight on the fairgrounds the following nights:

______Monday, August 1st                                                ______Tuesday, August 2nd

______Wednesday, August 3rd                                          ______Thursday, August 4th

______Friday, August 5th                                                    ______Saturday, August 6th

 

Reason for request:________________________________________________________

 

 


I will spend the night(s) in the following building:________________________________

 

I have read and agree to abide by the rules and regulations for spending the night on the fairgrounds listed on the reverse side.

 

                                                                                                ___________________________________

                                                                                                Signature of Member

 

 


                I am aware of the above arrangements and give permission for my child to spend the designated evenings overnight on the fairgrounds with the adult I have designated being responsible for him/her.  I understand that I can check which nights my child is signed up for by calling the Cornell Cooperative Extension of St. Lawrence County Office at 379-9192 or appropriate FFA teacher.  I realize that at no time will my child receive immediate supervision form the Cornell Cooperative Extension staff in St. Lawrence County.

 

                                                                                                ____________________________________

                                                                                                Signature of Parent or Legal Guardian

 

                If you are unable to contact me for any reason, please contact:

 

___________________________                 ___________________________________

Name                                                                                     Telephone Number

 

 

 


I agree to chaperone the above-mentioned youth and to assume responsibility for their actions.  I have read the rules and regulations listed on the reverse side connected with this agreement.

 

____________________________________                            _________________________________

Signature of Designated Chaperone #1                                          Date Responsible For

 

____________________________________                            __________________________________                                                                                                

Signature of Designated Chaperone #1                                          Date Responsible For                                         

 

____________________________________                            __________________________________                                                                                                

Signature of Designated Chaperone #1                                          Date Responsible For