Payment Information. Where did you hear about camp? I request to room with (may list only one request):

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2 Payment Information Please indicate below which method of payment you will choose: Option #1: Payment Plans can be arranged. Simply let us know and we will set up a payment plan for you. All payments must be paid in full by Friday, May 31, Option #2: Apply for a Scholarship. You may be eligible for a scholarship. We encourage campers and families to pay as much as possible toward the camp fee. A $25.00 Non-Refundable Deposit is required by every applicant to ensure that a spot is held for them. Scholarships are based on financial need and date of application, due to a limited number of scholarships. Applications should be submitted as soon as possible, but NO LATER THAN FRIDAY, May 10, Amount needed: $ Option #3: Pay Amount in Full requesting payment plans or scholarships. Full amount must be submitted no later than Friday, May 31, Camper s Name: Address: City: State: Zip: Birth Date: Camper s Age: Circle One: Male / Female Race: School Attending: T-Shirt Size (circle one) S M L XL (Shirts are adult sizes) Parent / Guardian: Home Phone: Cell Phone: Years attended 4-H Camp (Not including this year): I request to room with (may list only one request): Where did you hear about camp?

3 Kentucky 4-H Camping 2019 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: County: Gender Identity: Male Female Shirt Size: (Circle One) YS YM YL YXL AS AM AL AXL A2XL A3XL A4XL Birthdate: / / Age on 1st day of camp? Participant s Home Address: Street City, State, Zip Participant s Race: White Black Asian American Indian Hawaiian Cannot be determined Other Participant s Ethnicity: Hispanic Non-Hispanic Legal Parent/Guardian #1 Full Name: Address: Cell/Home Number: Legal Parent/Guardian #2 Full Name: Address: Cell/Home Number: Emergency Contact Full Name: Relationship to Participant: Cell/Home Number: Physician Name: Physician Phone Number: Buy your participant some camp gear. Is your participant looking for more camp opportunities?

4 PARTICIPANT NAME: Is the camp participant up-to-date on immunizations as outlined by Kentucky law required for enrollment in public, private, or home 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. Use tape, DO NOT staple.) 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 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, or been dizzy during exercise? Ever had chest pain during exercise? Had problems with sleepwalking? Ever had seizures? Ever had emotional difficulties? Ever had an eating disorder? 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? Carry an epi-pen or inhaler? YES NO Are there any specific behaviors, medical needs, dietary needs, accommodations, or information which the staff should be made aware of to provide a better camp experience for the participant? (Provide details for any questions above marked YES): Are there accommodations during the school year that your child requires we should plan for at camp? (i.e. accommodations for 504 and IEP Plan):

5 PARTICIPANT NAME: AUTHORIZATIONS/RELEASES This is a legal document. You must read and understand it before signing it. MEDIA RELEASE: I grant the Kentucky 4-H Program and the University of Kentucky, Kentucky State University, 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. 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. Parents, Guardians, and Emergency Contacts listed on page 1 and 2 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# CONSENT TO TREAT: The health history reported on page one and two are correct and complete to the best of my knowledge. 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 off camp property. CODE OF CONDUCT: I have read and discussed the Camp Code of Conduct with my participant. We (parent/guardian and participant) understand and agree to comply with the guidelines. Violations may result in loss of privileges, removal from camp with no refund, assessment of a damage fee for which 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. ASSUMPTION OF RISK, RELEASE OF LIABILITY, and PERMISSION TO PARTICIPATE: 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, Kentucky State University, 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. 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 (including, but not limited to: high ropes, rock climbing, low challenge elements, rifles, archery, trap shooting, horses, and cave exploration). Participant Signature: Date: Parent/Guardian Signature: Date:

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7 Camper s Name: County: 4-H CAMP CLASS SIGN UP FORM This year you will get to sign-up for four special classes, in addition to all the other activities in which you will automatically be participated. Please number the following classes 1 through 10 ( One being your first choice and ten being your last choice). We will try to give you as many of your top choices as possible. Please consider your class choices carefully. Class descriptions are listed on the back. There will NOT be an opportunity to change classes once camp begins. CLASS SIGNUPS ARE ON A FIRST COME, FIRST SERVE BASIS. THE SOONER THIS FORM IS TURNED IN THE BETTER CHANCE YOU HAVE OF GETTING YOUR TOP 4 CHOICES Advanced Swimming Archery Basketball Beginner Swimming Bicycle Canoeing Carpetball Crafts Fishing Foods Gaga Ball High Ropes Low Ropes Nature Photography Recreation Riflery Rocketry Scrapbooking Survival Skills Talent Volleyball Campers who DO NOT return this form will have activities chosen for them! Call for more information GET THIS IN ASAP!!!!

8 Class Descriptions Advanced Swimming: Swimming classes for the experienced swimmer ONLY! Swimming Test will be given to each camper before you will be able to take this class. Do not put advanced swimming as a choice if you do not know how to swim. Archery: Campers will learn shooting safety and how to shoot a bow and arrow under the instruction of a well trained coach. Scrapbooking: Campers will get to work on their own special scrapbook. Beginner Swimming: Trained lifeguards will teach you how to swim and water safety. Basketball: Join your fellow campers in a friendly game of B-Ball! Photography: THIS CLASS WILL ONLY TAKE PLACE IF HIGH DEMAND. (BASIC KNOWLEDGE OF PHOTOGRAPHY.) Nature: Take hikes and learn about the environment with a trained instructor. Recreation: Come and join your fellow campers in games and dances under the shelter house. Riflery: Learn firearm safety and how to shoot from a well trained coach. Low Ropes : Mission impossible? Challenge your mind and body to complete your mission through the maze of ropes! High Ropes and Climbing Wall: Climbing wall and zip line! Volleyball: Learning the basics and having fun. Bicycle Class: Learn bicycle safety and have a great time riding around camp! Canoeing: Learn about water safety and about canoeing. Fishing: Enjoy time on the lake with your fellow campers trying the catch the big one! Foods: Each camper in this class will learn about creating healthy, kid friendly foods. Crafts: Assorted craft projects. Rockets: Learn to design and launch rockets. Talent: This class is designed for those who want to prepare and practice performing arts. Volleyball: Learn the basics of volleyball while having fun. GaGa Ball: A camp tradition and an odd form of dodgeball. Carpetball: The newest game at camp that is a monster version of marbles on a table.

9 Kentucky 4-H Camping Code of Conduct and Expectations 1. Campers are not permitted to bring cell phones to camp 2. Possession or use of alcohol, illegal drugs, or weapons by any person is prohibited. 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 gender is not, at any time, to enter a restricted area. 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. Campers are to be attentive, responsive and courteous to any staff, adult or teen counselor making a presentation before the group. 7. 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. 8. Accidents or illnesses, no matter how minor, are to be reported to the Healthcare Provider and County Agent. 9. Obscene, discriminatory and/or inappropriate language or dress, roughhousing, and insubordination is not acceptable at any time during camp. 10. Fireworks are not to be used by campers at any time during camp. 11. Swimming, boating, or any waterfront activity is not permitted except during designated times and under proper supervision. 12. Appropriate dress, including footwear, should be adhered to as outlined at camper orientation. 13. Campers are always to remain with their groups, and must obey the rule of 3 when traveling. Individuals are not to be on the trails or near the lakes without an accompanying adult. 14. 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. 15. All campers are expected to be in their cabins, with lights out, as designated on the camp program. 16. No visitors, other than parents or immediate family, may visit campers during the camp. 17. No camper is to be around or on maintenance equipment. 18. Campers who are having personal conflicts with other campers should discuss these with their cabin counselor, dean or County Extension Agent. 19. 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. Campers are expected to leave the cabins, facilities and grounds clean and orderly.

10 20. 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. 21. 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. 22. Camp is not responsible for personal property of any camper, volunteer or staff. 23. We care about the safety of all camp participants, 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 County Extension Agent and an incident report will be completed. 24. 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. 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. 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. Participant Signature Parent/Guardian Signature Date

11 DISCIPLINARY PROCEDURE FOR YOUTH AT 4-H CAMP **Only adults and 4-H agent can enforce disciplinary action. Teen leaders are to inform adults or 4-H agent if disciplinary actions are necessary. The 4-H agent is the only person who can change the disciplinary list. Adults and teens must follow the list below and must inform the 4-H agent if disciplinary action is necessary. 4-H agent has the right to change the discipline schedule if a problem is continuous or if endangerment of camp participants is possible. The following applies to ALL 4-H campers and teen leaders that attend 4-H camp. These apply to ALL the camper rules and expectations. First Problem- Warning Second Problem- Loss of sally time and pool time for one day Third Problem- Loss of pool time and sally time for rest of the stay Fourth Problem- Send home *During loss of pool or sally time camper will be doing an assigned clean-up activity on the camp grounds. This activity will be assigned by the 4-H agent only. Refusal to do clean-up activity will result in camper being sent home. The following problems will result in the camper or teen leader being sent home immediately. *Out of cabin after lights out *Fighting *Possession or use of alcohol, drugs, or other illegal items *Endangerment of camp participants *Flagrant violation of any of the camp rules I understand that if a parent or listed emergency contact cannot be reached, the child will be delivered to County Sheriff s Office. Camper s Signature Date Parent/Guardian s Signature Date Process for handling camper discipline problems If the agent has determined that a camper must leave camp due to discipline problems or inappropriate behavior, the first step is to contact the parent/guardian to make arrangements for them to pick up the camper and explain the issue at hand The county policy for determining when parents are called based on behavioral issues is handled on a case by case basis. First of all: all behavioral issues are handled by the cabin counselors who have received full training in serving as a camp counselor. When campers are questioned, it is done with another adult or teen witness present. If the cabin counselor deems the behavioral issue too severe to handle, the county agent is called in to listen to the issue and make decisions about consequences, parent notification, etc. The following is the procedure followed at 4-H camp. All sides of the story are heard from all parties involved. The camper in question is showed the code of conduct form in which he or she read and signed and the parent read and signed prior to attending camp. The broken rule is identified and agreed upon by both parties. Consequences are discussed by the counselors and agent and agreed upon. The camper is then notified of the decision with input of agreement from the camper. The county agent then calls the parent and updates them on the situation with the adult or teen counselor present to listen to the phone call home. The incident is documented for future questions or problems.

12 Kentucky Residential 4-H Summer Camp Lice Policy The University of Kentucky 4-H Camping Program has a No Nit Policy. Participants identified to have nits or lice, through a head check, will not be permitted to attend camp. This head check must take place within a 72-hour period preceding boarding the bus for camp. It is the County Extension Agent s responsibility to inform parents of the No Nit Policy and the proper procedure for getting a head check for lice for their child before camp. Refunds are not provided to campers sent home after the first night of camp. There are two acceptable methods of lice head checks: 1. The county extension office makes arrangements for a nurse or other trained personnel to conduct a head check of all campers at the bus pickup area upon check in for camp. A checklist is maintained on all who received a head check. Any child who is found to have nits or lice through this head check, will not be allowed to board the bus and attend camp. The decision made during this head check is final. No other opinion or head check will be accepted. 2. The county may require parents/guardians to have a head check conducted by the local school nurse/health department or other qualified medical personnel within 72 hours of checking in for boarding the bus to camp. The clear head check form must be completed and signed by the medical personnel and presented to extension personnel or designated camp volunteers before boarding the bus for camp. If head lice or nits are suspected or detected at camp, the following procedures should be followed: Any head check deemed necessary at camp to identify possible head lice should be conducted discreetly, to not embarrass the camper (s). Anyone with confirmed head lice or nits through a head check or head lice comb should be inconspicuously separated from other campers to avoid an infestation. A volunteer should be assigned to stay with the camper, support them and relieve any fears or embarrassment. If one camper is determined to have head lice or nits, other campers in the cabin should be examined to avoid further infestation. Upon confirmation of head lice or nits, the parents/guardian of the camper (s) should be contacted immediately by the county 4-H agent and instructed to pick up their child, so that they may receive treatment. The camper (s) will not be permitted to return to camp even after treatment. A lice information letter should be given to the parent/guardian when they pick up their child. No chemicals should be applied or sprayed in the cabin area. There should be no chemical treatment at camp for head lice or nits. This is a parent/guardian s decision, not ours. ALL CAMPERS WILL HAVE HEAD CHECKS AT CAMPER ORIENTATION!