Summer 4-H Camp June 3-7, 2019 North Central 4-H Camp, Carlisle, KY

Transcription

1 February 7, Summer 4-H Camp Teen Counselors: Cooperative Extension Service Clark County 1400 Fortune Dr Winchester, KY Fax: Summer 4-H Camp June 3-7, 2019 North Central 4-H Camp, Carlisle, KY Junior Counselors in Training (JCIT): years old (As of June 7, 2019) Junior Counselors (JC): years old (As of June 7, 2019) Being a 4-H Camp Counselor is a great way to build leadership skills, by motivating campers in group games, helping campers adjust to group living, leading camp songs, teaching workshops, making new friends and learning life skills that will help you build your resume and grow as an individual. Did we mention you get community service hours? Mark your calendar with the following mandatory dates: Application Deadline: Friday, March 15, 2019 (by 4:00pm) Junior Counselor Interviews: Week of April 29-May 3 at GRC/Extension Office All Counselor Orientation: Saturday, May 25, 2019 at North Central 4-H Camp Camper Orientation: Tuesday, May 28, 2019 (evening) Camp: June 3-7, 2019 You can make a difference in a camper s experience at 4-H Summer Camp! Without you camp would not be possible! Please contact the Clark County Extension Office for application packets and with questions at (859) or Shannon.farrell@uky.edu. Sincerely, Shannon Farrell Brandy Calvert Clark County Agent for Clark County Agent for 4-H Youth Development 4-H Youth Development

2

3 COUNSELOR NAME _ 4-H Summer Camp Application Packet 2019 June 3-7, 2019 TEEN Clark County Extension Office 1400 Fortune Dr. Winchester, KY (859) Due by Friday, March 15, No later than 4:00pm! Read carefully and fill out each section: Fill out/sign/date 2019 Registration/Health (3 pages) (Read each section carefully and complete ALL boxes) Insurance Card (photo copy of card, front and back, TAPED to application) Read/Sign/Date Camper Code of Conduct Read/Sign/Date Damage Fees Read/Sign/Date Notification Policy Read/Sign/Date Junior Camp Counselor Position Description Fill Out/Sign/Date H Summer Camp Counselor App. (2 sides) 2 Counselor Recommendation Forms I understand both references are due by March 15, 2019 (Need 2). Following dates are on my calendar: Interviews: April 29-May 3 at GRC/Extension Office Orientation: May 25, 2019 At North Central 4-H Camp Camper Orientation: May 28, H Camp: June 3-7, 2019 APPLICATION RECEIVED BY: Date:

4

5 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?

6 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):

7 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:

8

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 Kentucky 4-H Camping Program Damage Fees The following contains only those items most frequently damaged or taken. Intentional damage to any other camp property will be assessed at the time of damage. Should intentional damage or theft occur, it is the responsibility of the child and his/her parents to reimburse the costs. No charges are made for worn equipment or normal usage. Charges are required for damage resulting from horseplay and malicious or intentional behavior. Graffiti on camp property will not be tolerated. Fire Extinguisher Discharged or broken Screen Door Repair or Replace Bunk Bed Bed Replacement / repair Cost of replacement Graffiti Defaced with Graffiti Mattress Replacement Smoke/CO Detector Damaged or missing Windows Repair or Replace 100+ HVAC Controls Repair/Replace 100+ Cabin HVAC Replace or repair Window Fans Replace Window Screens Replace First Aid Kits Lost or missing Brooms, Mops Broken or missing Dust Pans Broken or missing Trash Cans Broken or missing Basketball Rim Broken or missing Basketball Backboard Broken or missing Cost of replacement Cabin Keys Lost or missing or broken Changing Tents Damaged or missing Other ANY DAMAGE TO ANYTHING NOT LISTED INCLUDING PROGRAM EQUIPMENT WILL BE BILLED AT THE COST OF REPAIR/REPLACEMENT. I understand that I am responsible for paying for any damages that my child may cause to camp property. Parent/Guardian Signature Date

12

13 Clark & Montgomery Camp Notification Policy Notification of Changes Parent(s)/guardian(s) listed on the camp form will be notified of changes from the schedule as indicated through Remind text messages and/or telephone calls. Parents will be notified (using the first number provided on the custodial/guardian line of the campers form) of any changes in time or location on the departure day and the arrival day. Please be sure that the number you provide us is a phone number at which you can be reached at any time. Injury/Illness Parents will not be notified of every bump, bruise, or minor illness. Parents will be notified when the Health Care Professional deems it necessary and/or off-site medical treatment is needed. Emergency Policy If an emergency situation arises that directly involves a camper, parent/guardian(s) of the camper will be notified by one of the 4-H Agents or their designated representative at a time deemed appropriate and safe by the agents. Cell Phones Campers are not permitted to have cell phones while at camp. Being at camp includes transportation to and from camp. Parents will not be notified when a camper has their cell phone confiscated. Phones that are confiscated will be turned off, placed in a safe storage, and returned to the camper upon return from camp. Disciplinary Issues The Clark or Montgomery County 4-H Agents will be consulted on all disciplinary issues by the teen leaders/adult leaders. Camp rules must be followed. A camper s or teen leader s parent/guardian will only be notified of any flagrant violation of camp rules. A flagrant violation will result in the camper/teen leader being sent home and must be picked up at camp by parent/guardian or someone from their pickup/release list. Refusal to Pick Up Camper/Teen Leader When a parent/guardian is notified that they need to come to camp and pick up their camper/teen leader, they must do so in a timely manner. The agents don t make the decision to send someone home (either for illness or discipline) unless it is absolutely necessary. In a timely manner should be within a four hour window of first being notified. Failure to pick the camper/teen leader up in a timely manner may result in the local child services being called. Also, on the return day from camp, an approximate time is given in the orientation packet. Failure to pick-up (within two hours of estimated time of arrival or actual arrival time, whichever is latest) camper/teen leader by someone from the pick-up list provided by the parent/guardian may result in local child services being called. I have read and understand the above policy. Parent/Guardian/Adult Volunteer Date

14

15 VOLUNTEER POSITION DESCRIPTION: Kentucky 4-H Youth Development Program Kentucky Cooperative Extension The University of Kentucky College of Agriculture, Food and Environment POSITION TITLE: H Summer Camp Junior Counselor 4-H CAMP COUNSELOR TIME REQUIRED / DURATION OF APPOINTMENT -Must read and complete orientation materials -Complete all application materials and have references completed by March 15, 2019 by 4:00pm -All Counselors must interview on week of April 29-May 3, Attend All Counselor Orientation, Saturday, May 25, Attend Camper Orientation, Tuesday, May 28, Five Days and Four Nights of Camp (Monday-Friday), June 3-7, 2019 LOCATION: JC/CIT and Camper Orientations held at the Clark County Extension Office Camp at North Central 4-H Camp near Carlisle, KY in Nicholas County GENERAL PURPOSE: Help supervise youth, ages 9-13, in a camping setting Support 4-H professionals, volunteers and members in conducting meaningful educational experiences to help youth develop social skills. SPECIFIC RESPONSIBILITIES: Be committed to the development of young people Provide leadership and direction while working closely with adult counselors and agents Involve campers in all scheduled activities while at camp Make sure campers are on time for programs Under the direction of the adult counselor in your cabin, supervise group living environment (i.e. housekeeping, personal hygiene, social skills, responsibility, sharing, following rules, discipline campers) See that campers carry out responsibilities such as cabin cleanup, grounds cleanup, dining hall cleanup, etc. Participation in all camp activities including swimming

16 Counsel homesick campers Be responsible for the health, safety and happiness of each camper in their cabin Participate in implementing the camp s program Report any problems to your adult counselor, Dean of Men/Women, or County Agent Assist class instructors where needed in teaching or in managing campers behavior Assist adult counselors, permanent staff and agents, upon request, with special activities such as quiet time, flag raising/lowering, etc. A willingness to become familiar and work with the philosophy, guidelines and rules of the University of Kentucky CES, Kentucky 4-H Youth Development Program and the county 4-H program QUALIFICATIONS: Must complete all Clark County 4-H Summer Camp Counselor Application forms and go through interview process Self-starter; be able to work with minimal supervision from professional staff. Effective communication skills. A sincere interest in working with extension staff, volunteers, parents, and youth. Organizational skills; ability to organize information and materials in a timely manner. MUST BE 14 YEARS OR OLDER BY JUNE 7, Ability to get along with others Willingness to follow rules I understand the position description as given to me by the Clark County 4-H Youth Development Agents. I also understand my role as Junior Counselor during the week of 4-H Summer Camp. Junior Counselor Signature Date Supervising Agents Signatures Date Please sign and return with JC Application to: Shannon Farrell & Brandy Calvert Due by March 15, 2019 by 4:00 pm! 4-H Youth Development Agents Clark County Extension Office 1400 Fortune Drive Winchester, KY (859) shannon.farrell@uky.edu brandy.calvert@uky.edu OFFICE USE ONLY: DATE RECEIVED:

17 2019 Application 4-H SUMMER CAMP COUNSELOR (APPLICATION DUE: Friday, March 15, 2019 by 4:00pm) Applying for: COUNSELOR-IN-TRAINING (JCIT) (Check one) (14 or 15 years of age as of June 7, 2019) JUNIOR COUNSELOR (JC) (16-18 years old as of June 7, 2019) Name: Age: (as of June 8, 2018) Gender (circle one): M F Address: Zip: Counselor Phone: ( ) Date of Birth: / / Parent/Guardian Name(s): Phone: School: Current Grade: Have you ever attended 4-H Camp? (circle) Yes No How Many Years: Have you ever been a camp counselor before? (circle) Yes No How Many Years: List any previous responsibilities as a counselor: List previous and current 4-H and School events and activities you have been involved with: List previous and current school activities/clubs you have been involved with:

18 2019 Application 4-H SUMMER CAMP COUNSELOR Do you hold any current certifications in CPR, Lifeguarding, etc.?: (List): Describe any experiences you have working with younger children: Why do you want to be a 4-H camp counselor?: What qualities do you have that would make you a good camp counselor: Please have references complete and sign attached recommendation forms place in sealed envelope, return by mail to Extension Office, hand deliver or scan and to heather.cassill@uky.edu. Reference should not be parent/guardian or related to the applicant. All forms must be turned in by March 15, 2019 by 4:00pm. List names and phone number of references below: 1) 2) I understand that my attendance at each of the following events in addition to camp is mandatory to participate in 4-H Summer Camp as a Camp Counselor. By initialing each line below I understand that I must be present at each event to be eligible to attend 4-H Summer Camp as a Junior Counselor in Training or a Junior Counselor. Failure to attend one or all of these events may result in being removed from the 4-H Summer Camping Program as a Camp Counselor. Week of April 29- May 3 at GRC/Extension Office (All Counselors are required to Interview) Saturday, May 25 (All Counselor Training) at North Central 4-H Camp Tuesday, May 28 (evening) (Camper Orientation) If I am selected as a 4-H Summer Camp Counselor I understand that the following materials must be turned in by Tuesday, May 28 th. New Counselor Training Modules (Will be mailed to address on application if you are selected as a counselor.) SIGNATURE OF APPLICANT: Date: SIGNATURE OF PARENT/GUARDIAN: Date:

19 Clark County 4-H Counselor Recommendation Form Teen Leaders for 4-H Summer Camp 2019 Please complete the following form, place in a sealed envelope. Recommender may choose to mail to the Clark County Extension Office (1400 Fortune Drive, Winchester, KY 40391), return to applicant in secured envelope or scan/ to: shannon.farrell@uky.edu. Please remember recommender should not be parent/guardian or related to applicant. All reference forms are due by Friday, March 15 th, 2019 at 4:00pm. Name of Person Completing Reference Form: Name of Person Reference is for: Relationship to Applicant: How many years have you known applicant? Please rank the applicant in the following areas based on your first-hand knowledge of him/her: Strong Adequate Weak Not Observed Specific Comments Emotional Maturity Physical Stamina Enthusiasm Team Player Leadership Skills Stress Management Decision Making & Problem Solving Skills Ability to Handle Conflict Interaction/Connection with children Interaction/Connection with adults Interaction with Supervisors/Authority Figures What would you consider to be the applicant s greatest strengths? If you could encourage the applicant to grown in any way, what would it be and why? -continued on reverse-

20 Please mark the words below that best describe the applicant (choose all that apply): Team Player Organized Responsible Critical Punctual Role Model Flexible Honest Confident Approachable Productive Bossy Creative Safety-Minded Helpful Loyal Easy Going Unpredictable Athletic Positive Dependable Arrogant Influential Enthusiastic Judgmental Cooperative Outgoing Untidy Prepared Respectful If your opinion, is the applicant able to cope with potential challenges that come with working with children? yes no If no, please comment: Please provide any additional information that you feel would help in our decision making process as we choose our volunteer team for 4-H Summer Camp Would you recommend this applicant as a Teen Leader for 4-H Summer Camp 2018? yes yes, with some reservations no Signature of Reference: Date: address: Phone: 2

21 Clark County 4-H Counselor Recommendation Form Teen Leaders for 4-H Summer Camp 2019 Please complete the following form, place in a sealed envelope. Recommender may choose to mail to the Clark County Extension Office (1400 Fortune Drive, Winchester, KY 40391), return to applicant in secured envelope or scan/ to: shannon.farrell@uky.edu. Please remember recommender should not be parent/guardian or related to applicant. All reference forms are due by Friday, March 15 th, 2019 at 4:00pm. Name of Person Completing Reference Form: Name of Person Reference is for: Relationship to Applicant: How many years have you known applicant? Please rank the applicant in the following areas based on your first-hand knowledge of him/her: Strong Adequate Weak Not Observed Specific Comments Emotional Maturity Physical Stamina Enthusiasm Team Player Leadership Skills Stress Management Decision Making & Problem Solving Skills Ability to Handle Conflict Interaction/Connection with children Interaction/Connection with adults Interaction with Supervisors/Authority Figures What would you consider to be the applicant s greatest strengths? If you could encourage the applicant to grown in any way, what would it be and why? -continued on reverse-

22 Please mark the words below that best describe the applicant (choose all that apply): Team Player Organized Responsible Critical Punctual Role Model Flexible Honest Confident Approachable Productive Bossy Creative Safety-Minded Helpful Loyal Easy Going Unpredictable Athletic Positive Dependable Arrogant Influential Enthusiastic Judgmental Cooperative Outgoing Untidy Prepared Respectful If your opinion, is the applicant able to cope with potential challenges that come with working with children? yes no If no, please comment: Please provide any additional information that you feel would help in our decision making process as we choose our volunteer team for 4-H Summer Camp Would you recommend this applicant as a Teen Leader for 4-H Summer Camp 2018? yes yes, with some reservations no Signature of Reference: Date: address: Phone: 2