CABIN SIGN UPS ARE TONIGHT ONLY YOU MISS, I ASSIGN YOU A CABIN YOU ATTEND, YOU DECIDE NO EXCEPTIONS!

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1 January 24, 2018 Cooperative Extension Service Butler County 112 E GL Smith St/PO Box 370 Morgantown, KY (270) Fax: (270) To: From: 4 H Campers, Teens and (s) Lloyd G. Saylor County Extension Agent for 4 H Youth Development We have received your application for camp. Enclosed you will find the additional forms required for 4 H Camp. The following information is very important so please read over it carefully. Butler County 4 H ers will attend camp at the Western Kentucky 4 H Camp in Dawson Springs, July 16 20, Butler County will camp with Crittenden, Todd, Logan, and Hickman Counties this year. If you decide NOT TO ATTEND 4 H camp, please call immediately!!!!! (All Forms & Fees are due Friday, June 22nd) No late forms taken the day of camp!!! Please read the following information carefully and return the enclosed forms to the County Extension Office. Campers will not be allowed on the bus without all completed and signed forms returned and all fees paid! (Camp has a no nit policy and if lice are found, you will be sent home and there will be no refund of camp fees.) Camper Orientation will be July 12 th at the Extension Office at 6:00 pm. Teen/Adult Leader Orientation will be July 12 th at the Extension Office from 9am 3pm. At this orientation, we will.. * go over camp activities * turn in any missing camp paperwork. Packets should be turned in by June 22nd. * look over the camp classes * cabin sign up If YOU have someone you want to be in the cabin with. * answer any questions you or your parents may have CABIN SIGN UPS ARE TONIGHT ONLY YOU MISS, I ASSIGN YOU A CABIN YOU ATTEND, YOU DECIDE NO EXCEPTIONS!

2 Please read everthing carefully. There are some new changes this year!!! REGISTRATION/HEALTH FORM WHITE FORM (Mandatory) Each parent must complete the UK Camp Participant Registration form. All parts must be completed and signed. We do not have to have a copy of shot records, you will check yes or no on the form. However, if your child is not up to date on shots, you must complete the Immunization Waiver form included in this packet. A copy of the current health insurance card or current K chip must be attached to the registration form if your child has insurance. LICE CHECKS BLUE FORM (Mandatory) This must be completed between June 20th July 9th. Deadline to turn this form in is on July 9th. This will need to be completed by a non family member, extension service personnel, a volunteer, medical personnel, hair dresser or school teacher. We will provide lice checks at the office on JULY 5 TH AND JULY 9 TH FROM 8:30 am 3:30 pm. IF YOUR CHILD HAS NOT BEEN CHECKED BY THE MORNING OF CAMP, YOUR CHILD WILL NOT BE ALLOWED TO GO! WE WILL NOT COMPLETE LICE CHECKS ON THE MORNING OF CAMP!!!!! CAMP EXPECTATION FORM GREEN FORM (Mandatory) Each camper and parent must read and sign the camp policy form enclosed in this packet. Campers will not be allowed to attend camp without a signed camp policy form. MEDICATION FORM PINK FORM (Optional) All camper medication for the week must be turned in on Monday at the medicine registration table. Please leave medicine in original containers and place the medication and your pink form in a ziploc bag. Make sure the medication form is properly labeled with name, medication title, time schedule and dosage. DO NOT PUT YOUR MEDICINE IN YOUR LUGGAGE WE MUST TAKE ALL MEDICINES AT THE COUNTER THE MORNING OF CAMP! The camp EMT will administer the medicine at camp. This includes all prescription and non prescription medicine! The camp EMT will provide Tylenol or Ibuprofen for your child only if needed with signs of fever or severe headache as long as it is checked on the health form. If you do not have medications, disregard this form. If you want to allow your child permission to take Tylenol or Ibuprofen, this form will need to be completed with the child s name and have your signature. Under the instructions section, simply write Tylenol or Ibuprofen as Needed. FOOD ALLERGIES If your camper has any food allergies, please let us know ASAP by calling, and by including on the camper forms. Camp is currently working on a menu for the week, and a copy can be provided. Other food arrangements will be made available if there is a known food allergy. CAMP CLASSES This year, each camper will sign up for camp classes on the first day at camp. Each camper will attend 4 classes on Tuesday, Wednesday and Thursday morning at camp. (Exception: those campers who take the challenge course classes will only attend 3 classes as the challenge course classes take up 2 periods. Some craft classes will be offered and generally have an additional $2 $4 charge (crafts will be brought home by campers). All class equipment will be provided at 4 H camp. Check out the Spending Money section below for an idea of money allowances. ORGANIZED RECREATION Every afternoon, you may participate in organized recreation activities. This year the recreation available will include basketball, ping pong, shuffle board, kick ball, jump rope/hoola hoops, board games, reading(bring your own books), softball, special crafts and volleyball. Balls and other equipment will be provided for all recreational activities. Complete schedules will be available on the first day of camp.

3 SPENDING MONEY 4 H ers may bring extra money for craft classes, country store, t shirts and other items. A roll of quarters is recommended due to the drink machines, which are open during the day. Do not send large bills! There will be three meals and two snacks provided each day, which is included in the camp fee. (see enclosed camp menu) Water will be available at all times. 4 H ers can usually get by on $15.00 to $20.00 in extra spending money for candy bars, chips, snow cones, drinks, etc., but free snacks are available at snack time if desired. The camp and 4 H program leaders will not be responsible for money lost or stolen. A pizza party on Thursday night will require a few dollars from each camper. This money will be collected on Tuesday night. Remember to allow spending money for classes requiring fees, crafts and souvenirs if desired. CAMP THEME The daily routine will be similar all week long, but the theme for camp Movies will spice things up a bit. We ll have decorations and fun games. Each cabin will be assigned to a crew number and this will be your team for the week. All week you will be competing against other crews for the spirit award. The winning group will get to carry the spirit stick around. Clean cabins, positive attitudes, and success at the Olympic events will earn points toward the spirit stick. WHAT TO PACK Please keep luggage to a minimum only bring what you can carry to the cabin on your own! Bell hops and luggage carriers are never around at 4 H camp! Bedding sheets, pillow and blanket or sleeping bag (beds are twin size bunks). Towels, wash cloths, soap (a daily shower is encouraged due to heat and bunk space). Beach towel for the daily swimming at the pool. Toothbrush, toothpaste, comb, deodorant and other personal care items. Casual clothing such as t shirts, shorts, socks, jeans (at least one change of clothing per day). (Please pack respectable clothing (no mid rift shirts or low cut tops, no shirts displaying under garments, tank tops are fine as long as the straps cover the undergarments) Remember this is a co ed 4 H camp). Two pair of shoes tennis shoes and other comfortable shoes (sandals with heal straps are allowed, but flip flops may only be worn to the pool and in the shower! (Flip flops tend to leave blisters after all day use, so they will not be allowed during class time, recreation or night programs.) Swim suit. (Shirts and shorts must be worn to and from the pool over your swim suit). s, please encourage your child NOT to wear their swim suits under their regular clothes all day. This results in galling. Light jacket or sweatshirt in case of cool night weather. (We can only hope!) ha ha. Large trash bag for dirty or wet clothes. Sun screen lotion, insect repellant (mosquitoes and chiggers can be bad)! (clear finger nail polish placed on chigger bites will kill the chiggers and decrease the itch.) It s a good idea for campers to make a list of everything he she packs and take it along in the suitcase in case items get lost. Also, put your name on all your items. By the end of the week, the lost and found box is usually full of unclaimed items. WHAT NOT TO PACK Some of these items are strictly prohibited refer to your camp policy form for details. Cell phones (calls from camp may only be made with permission from the 4 H agent!) Non adult monitored communications are not a good idea. Knives T.V. Electronic Games (Game boys, MP# players, IPODs and the like should be left at home) CD players/radios (your teen counselors will provide one in your cabin) Fireworks Firearms (camp provides all firearms for shooting sports classes)

4 Shaving Cream (may only be packed for shaving purposes) Water Guns Balloons Expensive Jewelry Weapons of any sort Coolers (daily access to cold drinks is available there s just not enough room for all to take coolers) Fans (your adult and teen counselors will provide these in the cabins.) Alcohol, drugs or tobacco products (strictly prohibited!) COUNTRY STORE AND SOUVENIR PRICES Each day, campers will have an opportunity to visit the country store. They may purchase 4 H Souvenirs, food or drinks. Most parents that WANT to send extra spending money usually don t send over $20.00 in small bills and/or change. Remember, spending money is entirely up to you. Your child will be responsible for keeping up with/handling his/her own money. CONTACTING A CAMPER AT CAMP s please do not ask that your child call home while away. In coming calls are also discouraged. Telephone calls generally contribute to increased homesickness. In case of emergency, call (270) Ask to speak to Lloyd G. Saylor. Letters are encouraged, but should be mailed early in order to be delivered during our week. Mail is handed out each day and campers get excited when they receive mail. Use the following address: 4 H Camp Campers name Butler County H Camp Road Dawson Springs, KY EMERGENCY TRANSPORTATION CHANGE/EARLY RELEASE PLAN In the event that we need to transport campers home early or there is a change in location for picking up camper, parent phone numbers are kept in a data base at the County Extension Office. A county staff person will notify our office personnel, which will then begin notifying camper s parents/guardians. The county staff will also have signs posted at the original location to direct parents to the new location in the event of a change in drop off for pick up. (The Butler County Extension Office is the original drop off/pick up location for 4 H camp.) In the event of the need to evacuate the busses to and from camp, the school s bus evacuation drill procedure will be followed. The transportation director will be notified immediately. If you have any questions about 4 H Camp, please contact the Butler County Extension Office at or send an e mail to Lloyd G. Saylor lsaylor@uky.edu. Looking forward to an outstanding 4 H camp! See you soon!

5 Butler County 4-H Camp Registration Monday, July 16, 2018 Friday, July 20, 2018 West Kentucky 4-H Camp, Dawson Springs, Kentucky Name (first) (last) Address (P. O. Box Number, if available, or street/address) (city) (zip code) Birthdate Age (on July 10 th, 2018) (month, day and year) School Grade (completed by May, 2018) Gender ( ) Male ( ) Female T-Shirt Size (youth or adult) Have you attended 4-H Camp before? ( ) Yes ( ) No How many years? /Guardian (Print first and last name(s)) Phone (Home) (Work) (Cell-a number we can send a text) Signature Date Return this form by JUNE 1, 2018 along with $225 to the Butler County Extension Service (Next to the Courthouse) Forms and checks may be mailed to: P O Box 370, Morgantown, KY Checks made payable to: Butler County 4-H Council Camp fees of $ are due along with this form by JUNE 1st FOR 1 ST TIME CAMPERS ONLY - I would like to request financial assistance for camp (A scholarship form will be sent to 1 st Time Campers ONLY if checked)) SCHOLARSHIP DEADLINE IS MAY 25, 2018 NO EXCEPTIONS. A down payment of $50.00 is due from all scholarship applicants along with this form. Scholarship recipients will be notified after June 10th the amount funded at which time, the remainder of the camp fees not funded will be due. A packet of additional 4-H Camp forms and full information will be mailed after June 1st, if not given to you at application turn-in. Call the 4-H Office at for additional information.

6 Kentucky 4-H Camping Program 2018 Camp Participant Registration Camper/Teen (Ages 5 to 17) Last Name: Legal First Name: Middle Name: Preferred Name: Attended camp before? Yes - # years: No School grade entering: What school does the camp participant attend? Gender: M F Shirt Size: (Circle One) YS YM YL AS AM AL AXL A2XL A3XL A4XL Birthdate: / / How old will the participant be on the first day of camp? Participant s home address: Race (check all that apply) American Indian Asian Pacific Islander White Black Hispanic Non-Hispanic Participant s LEGAL Custodial s/guardians #1 Full Name: Home Address: Address: Cell/Home Number: #2 Full Name: Home Address: Address: Cell/Home Number: Emergency Contact if above individuals are unavailable Full Name: Relationship to participant: Cell/Home Phone: Participant s Family Physician Name: Address: Phone Medical and Dietary Restrictions (list all known and reaction management):

7 CAMP USE ONLY (Healthcare Staff Review Stamp) Had any recent injury, illness, or infectious disease? Have a chronic or recurring illness/condition? Ever been hospitalized? Ever had surgery? Have frequent headaches? Ever been knocked unconscious? Wear glasses, contacts, or protective eyewear? Ever had frequent ear infections? Ever passed out, dizzy, or chest pain during exercise? Ever had an eating disorder? Had problems with sleepwalking? Ever had seizures? Ever had emotional difficulties? Carry an epi-pen or inhaler? Explanation of YES answers: YES NO Ever had high blood pressure? Ever been diagnosed with a heart murmur? Ever had back problems? Ever had problems with joints, knees, or ankles? Have an orthodontic appliance brought to camp? Have any skin problems (rash, acne)? If female, any abnormal menstrual history? Had problems with diarrhea or constipation? Had mononucleosis in the past 12 months? Have diabetes? Have asthma? Have a history of bed wetting? Have severe allergies? YES NO Behavior or Medical History Are there any other behavior needs, accommodations, or information which the staff should be made aware of to provide a better camp experience for the participant? Immunization Records Is the camp participant up-to-date on immunizations as outlined by Kentucky law required for enrollment in public or private school, based upon the grade the participant will be enrolled for the upcoming school year? YES NO (If marked NO, check with your 4-H agent for a waiver of liability form.) Does the participant have health insurance coverage? YES (Attach a copy front and back of the insurance card in the boxes below.) NO (No worries! Camp provides an excess medical insurance coverage in the event of injuries or illnesses.) FRONT OF INSURANCE CARD BACK OF INSURANCE CARD Do you want to buy your camper/teen some camp gear? Is your camper looking for more camping opportunities?

8 CAMP PARTICIPANT S NAME: AUTHORIZATIONS/RELEASES This is a legal document. You must read and understand it before signing it. Consent to Treat: The health history reported on page one and two are correct and complete to the best of my knowledge. The person herein described has permission to engage in all camp activities except as noted. I hereby permit the camp to provide routine health care, administer over the counter medication, assist in administering participant s prescription medications as needed, and seek emergency medical treatment including ordering x-rays and routine tests. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I permit the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby permit the physician selected by the camp to secure and administer treatment, including trips out of camp. Media Release: I grant the Kentucky 4-H Program and the University of Kentucky, and persons acting through them, the right to use, reproduce, assign, and/or distribute photographs, films, videotapes, and sound recordings of my minor child without compensation for use in promotion/advertising, educational publications, electronic publishing, and personal memorabilia. Participant names may be published. Yes. I grant permission for media releases. No. I do not grant permission for media releases. Code of Conduct: I have read and discussed the Code of Conduct with my participant. We (parent/guardian and participant) understand and agree to comply with the guidelines. Violations may result in the loss of privileges, removal from camp with no refund, assessment of a damage fee I will be responsible for paying, and/or ineligibility to participate in future 4-H events. An incident report will be completed for major violations Permission to Participate: I understand that my child s participation in the Kentucky 4-H Summer Camping Program is based on the challenge by choice philosophy. I recognize that programs are designed to use experiential, engaging teaching techniques, but that my child s participation is purely voluntary, always, and my child will choose his or her level of participation in any activity. The camp activities listed below require acknowledgement of the risks involved and permission to participant from the parent/guardian. Place a check indicating YES or NO next to each activity, and then sign below. YES NO YES NO High Ropes Horses (WKY only) Low Ropes Cave (LC only) Archery Firearms Pick-up Release: It is my responsibility to arrange to pick up my child/children upon return from camp. There will be no exceptions to this policy regardless of relationship to the child. Please inform everyone approved by you on this release that he/she must present a driver s license or photo ID before the child will be released. s, Guardians, and Emergency Contacts listed on page 1 are automatically assumed to have pick up authorization. In addition to the parents/guardians listed on page 1, the following individuals are granted permission to pick up my child NAME: RELATIONSHIP Phone/Cell# NAME: RELATIONSHIP Phone/Cell# NAME: RELATIONSHIP Phone/Cell# Assumption of Risk and Release of Liability: I acknowledge that there are certain risks, hazards, and dangers, including the risk of physical injury, disability, or death and risk of loss of use or damage to my personal property as a result of allowing participation in the camping program. Risks include but are not limited to recreational games and traditional camp activities, transportation accidents, weather-related hazards and natural disasters, infectious diseases, the possibility of slips and falls, pinches, scrapes, twists, and jolts that could result in scratches, bruises, sprains, lacerations, fractures, concussions, or even more severely debilitating or life-threatening hazards. I understand that injury or loss may result from unknown or unexpected risks and the use of equipment, materials, or facilities recommended by the University of Kentucky; environmental conditions; from the acts or omissions of others; or from the unavailability of immediate and adequate emergency medical care. I understand that the University of Kentucky does not guarantee the personal health or safety of participants, nor does it protect against the risk of loss of personal property. In consideration for allowing my child to participate in the camping program, I do hereby release Kentucky 4-H Camp, the University of Kentucky, and its members, trustees, officers, employees, independent contractors, volunteers and extension staff from any and all liability, damages, cost, and expenses arising out of or relating to bodily or psychological injury, loss of life, or personal property that may occur as a result of participating in the camping program. Participant Signature: Date: /Guardian Signature: Date:

9 Kentucky 4-H Camping Program Camper Code of Conduct / Expectations OM-4, 9 1. Possession or use of alcohol or illegal drugs by any person involved in the 4-H Camp Program is strictly prohibited. 2. Any weapon or article construed to be a weapon, hunting or pocket knife must be checked in with the Extension Agent from the camper's county upon arrival at camp. These items may be returned at the end of camp. The best prevention is to leave these items at home. 3. Use of tobacco products is not allowed for campers/teens at 4-H camp. Should a county(s) decide to permit adults (18 years and over) to use them, it may occur only in areas designated by the Camp Director. Absolutely no tobacco products in cabins, woods or other areas of camp. 4. Boys and girls cabin areas are restricted. A camper of the opposite sex is not, at any time, to enter a restricted area unless approved by the Camp Program Director. 5. Campers are not allowed in the cabins during a class or activity. If a camper is ill, he/she is to stay at the medical center (not in a cabin) until the Health Care Provider (HCP) feels the camper may return to activities. 6. There is to be no visitation to friends in cabins. 7. Campers are to be attentive, responsive and courteous to any staff, adult or teen counselor making a presentation before the group. 8. Absolutely no phone calls are to be made by campers (camp phone or cell phone) without approval of the County Extension Agent. All County Extension Agents should be informed of incoming calls to campers. 9. Campers are not permitted to bring cell phones to camp. 10. Accidents or illnesses, no matter how minor, are to be reported to the HCP and County Agent. 11. Obscene, discriminatory and/or inappropriate language or dress, roughhousing, and insubordination is not acceptable at any time during camp. 12. Fireworks are not to be used by campers at any time during camp. 13. Swimming, boating, or any waterfront activity is not permitted except during designated times and under proper supervision. 14. Appropriate dress, including footwear, should be adhered to as outlined at camper orientation. 15. Campers are always to remain with their groups. Individuals are not to be on the trails or near the lakes without an accompanying adult. 16. Campers are not permitted to leave the grounds at any time without notifying and receiving approval from the Camp Program Director and their County Extension Agent. 17. All campers are expected to be in their cabins, with lights out, as designated on the camp program. 18. No visitors, other than parents or immediate family, may visit campers during the camp. 19. No camper is to be around or on maintenance equipment parked or being used on camp property. 20. Campers who are having personal conflicts with other campers are encouraged to discuss these with their cabin counselor, dean or County Extension Agent. 21. Campers are to work with counselors in carrying out daily assigned jobs to help keep the camp running smoothly. Grounds are to be kept clean at all times. 22. Campers are expected to leave the cabins, facilities and grounds clean and orderly. 23. Campers are to respect camp property. Any malicious or intentional damage to camp property or buses shall be paid for by the camper and/or parent or guardian, including graffiti on any camp property.

10 24. All medications must be turned in to the designated adult and picked up by the parent/guardian at the bus pick up site. The Health Care Provider will be responsible for securing all medications at camp. 25. Electrical appliances (hair dryers, curling irons, etc.) are to be used in cabins only; not in restrooms. 26. Camp is not responsible for personal property of any camper, volunteer or staff. 27. We care about the safety of your child, incidents of serious misbehavior (i.e. fighting, bullying, causing injury, alcohol/drug incidents, any altercations between adults and/or minors, intentional property damage/vandalism, etc.) will be reported to the Camp Director and an incident report will be completed. 28. Campers should demonstrate respect toward others. Bullying, hazing or malicious pranks (i.e.: shaving cream, toothpaste in pillow/sleeping bags, defacing property, including inappropriate use of electronics/social media) will not be tolerated and may result in the perpetrator(s) being sent home. 29. Any conduct inconsistent with the above rules may result in consequences such as the camper/family/friend being sent home, restricting future participation in 4-H activities, termination of 4-H membership, or other consequences determined by the county s or state s policy. 30. If a camper must be sent home, it will be the responsibility of the parent/guardian to pick him or her up at camp. There is no refund of the camper fee for an early departure. Camper/Volunteer Signature /Guardian Signature Date

11 Kentucky 4-H Camping Program Waiver of Liability Immunizations Participant Name: County: To the best of my knowledge and belief, the person named above is and has been in normal good health and is free from all communicable or contagious disease. Should this participant show symptoms that reasonably indicate the presence of a communicable or contagious disease, I agree that a physical examination/assessment may be performed. I also agree that if any such disease is found, we the named individual and his/her family will comply with the quarantine or isolation procedures required of the camp as directed by the state s Department of Health. It is further understood that, should a communicable disease emergency arise, I will be notified. However, in the event that I cannot be contacted, the camp s administrator(s) and healthcare staff may take the temporary measures they deem necessary to protect the health status of this participant. I release and forever discharge the University of Kentucky, Kentucky 4-H Camping Program, its officers, employees, directors, employees, agents, insurers, affiliates, attorneys, or any other person or persons associated with any or all of them or any variation in the name of any or all of them who might be liable (the Released Parties) from all causes of action, suits, claims, demands, or any other damages or costs associated with actions taken by the Released Parties. I represent and acknowledge that I have read and understand this agreement and release and warrant that all statements made herein are true to the best of my knowledge. I further warrant and acknowledge that I am of legal age, legally competent to execute this agreement and release, and accept full responsibility therefore. /Guardian Signature Date *The original copy of this form should be attached to the camper s registration paperwork.

12 4-H Camp Medication & Prescription Form 2018 Participant s Name: Age: Weight: Camp: County: Cabin #: Contact Phone #1: Contact Phone #2: INSTRUCTIONS: The following must be completed for each medication brought to camp that is to be taken by you or your child during 4-H camp. Please list medications in the order in which they are to be taken. This includes inhalers. Fill in the name and dosage (as listed on the container) for each medication, along with any special instructions (take with food, etc.). Please place a in the appropriate Day/Time slot under the parent column for when medicine should be administered. Or check mark As Needed next to dosage if appropriate. (HCP will initial as medication is given.) In the event that your directions differ from those on the original container, you must obtain a note from the prescribing physician confirming the directions that should be followed in administering medications to my child. FOR CAMP USE ONLY: DATE: Health Care Provider: ( ) PLEASE SEND ONLY THE NUMBER OF PILLS YOU OR YOUR CHILD WILL NEED FOR THE CAMP SESSION - IN THE ORIGINAL CONTAINER(S). PLEASE LIST any medications that should be kept with the participant at all times (i.e. EpiPen, inhaler): 1. Name of Medication: Dosage: Special Instructions: Give As Needed: : Breakfast Lunch Dinner Bedtime Other Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 2. Name of Medication: Dosage: Special Instructions: Give As Needed: : Breakfast Lunch Dinner Bedtime Other Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 ALL MEDICATIONS MUST BE IN ORIGINAL CONTAINERS

13 Participant s Name: 3. Name of Medication: Dosage: Special Instructions: Give As Needed: : Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Breakfast Lunch Dinner Bedtime Other 4. Name of Medication: Dosage: Special Instructions: Give As Needed: : Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Breakfast Lunch Dinner Bedtime Other 5. Name of Medication: Dosage: Special Instructions: Give As Needed: : Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Breakfast Lunch Dinner Bedtime Other