Coshocton County 4-H Junior Camp July 5 th -9 th, 2017 Due to the Extension Office by June 9 th, 2017

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1 Coshocton County 4-H Junior Camp July 5 th -9 th, 2017 Due to the Extension Office by June 9 th, 2017 Your Name: Circle one: Boy Girl Address: City: Zip: Phone: Age: Grade Next Fall: Date of Birth: Parent or Guardian s Name: Emergency Contact Name: Emergency Contact Name: Phone: Phone: 4-H Member: (Circle one) Yes No Attended 4-H Camp at Camp Ohio before: Yes No Cabin Mate(s) Preferred (NOT GUARANTEED-No more than 2): Restricted Release for child at end of camp? Please Circle: Yes No If yes, obtain a 4-H Member Restricted Release form and give to the 4-H Educator before camp or at camp registration Camp Fee Coshocton County 4-H Members $180 Scholarships available from the 4-H Advisory Committee (deadline May 5 th ) Non-4-H Member $190 Camp: Scuba Diving $37 Scuba: High Ropes $10 (Age 12 and up) Ropes: 4-H Camp Lamp $6 Lamp: Subtotal: Frozen Food Discount (if applicable) FF Disct.: Sibling Discount $25 (per sibling) Sibling Disct.: GRAND TOTAL = PERMISSION TO PARTICIPATE COSHOCTON COUNTY 4-H JUNIOR CAMP, 4-H CAMP OHIO I give my permission for my child,, to participate in Coshocton County Junior Camp form July 5th-9th, Activities involved in camp will include living in a rustic cabin, sharing bathroom facilities with other campers, sleeping in bunk beds, canoeing, swimming, nature hikes, fishing, creeking, playing volleyball, basketball, relay races, water games, dancing, and other recreational games, shooting sports, trap shooting, and campfire activities. Attending the camp may lead to contact with individuals who are experienced and inexperienced in the above mentioned activities. I also understand that participation in this activity is strictly voluntary and is not a requirement for 4-H membership. I am aware and have discussed with my child that: 1. Being in and around water, woods, and participation in camp activities may cause clothing to become wet, dirty, and beyond cleaning and/or repair. 2. While in a canoe, my child may be involved in a collision with another canoe, person, or object in the water. 3. Hiking may give rise to risk on injury arising from the surface or subsurface of the ground in which the hiking occurs. 4. Participation in sporting/recreational events may give rise to injury as a result of collisions with another individual or sudden falls. 5. Other participants may act in a negligent manner which otherwise may result in harm to my child. 6. Swimming may lead to injury caused by slippery surfaces, contact with other swimmers and/or objects in the water. I recognize that the above mentioned activities and potential resulting risk may cause injury, death, drowning, or loss to participants or other persons in the immediate vicinity. I understand that my child is not required to participate in this activity, but grant permission for him/her to do so, despite possible risk. I recognize that by participating in this activity, as with any physical activity, my child may risk personal injury. I hereby attest and verify that I have been advised of potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. Signed: (Parent/Guardian) Signed: Date: Date: (Camper)

2 THE OHIO STATE UNIVERSITY EXTENSION So you are going to 4-H Camp! Do NOT bring to camp: Any cell phones or walkie-talkies Shaving cream You will need to bring: Bedding pillow, sleeping bag, or blankets Clothing for play and swimming Rain Gear Old shoes that can get wet for stream study Older clothes for outpost, camping, fishing, and creeking Long-sleeved shirt and long pants for evening programs and high ropes Sturdy shoes/tennis shoes and socks to wear during camp. Flip flops/sandals are only to be worn to the pool or shower (flip-flops result in toe and foot injuries at camp). Shoes are also needed for outpost, high ropes, and zipping. NO FLIP FLOPS OR SANDALS ALLOWED AT THE DANCE - MUST BE STURDY SHOES. Toiletries sunscreen, washcloths, towels, soap, toothbrush, toothpaste, mosquito repellent (non-aerosol) Crafts bring cotton (100% cotton is best) t-shirt, hankies, or socks for tie-dying Bring a nice summer outfit for dancing and having fun at the final dance the last evening Money a small amount for purchasing at camp store (Please do not bring a large amount of money or any valuable items!) A big smile and positive attitude to have lots of fun Bring lots of enthusiasm and energy for a great camp! Camp Ohio Rules You Should Know: Shoes must be worn at all times except when swimming, showering, or sleeping. Proper attire is to be worn at all meals no tank tops, halter tops, or swim suits. Hats should be taken off upon entering the dining hall. Boys are prohibited from entering the girl s cabin areas; girls are prohibited from entering the boy s cabin areas. Football playing is prohibited because it is not covered by insurance. As a means of risk management, youth participants (campers and counselors) are no longer permitted to possess cell phones during camp. 4-H Camp Ohio staff maintains the right to confiscate cell phones during camps and turn them in to Visiting Camp Directors. Coshocton County staff has the right to send campers and counselors home immediately if found with cell phones. Youth arriving late or early should sign in or sign out at the Cow Palace/Nurse s Station Respect should be shown for others and their belongings at all times. If you must call during camp the Cow Palace number is , Camp Ohio staff will answer this line during office hours only if it is not picked up at the Cow Palace. ARRIVAL/DEPARTURE TIMES You will be arriving at camp 3:00-4:00PM July 5 th You will be going home at 10:00AM July 9 th CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For more information: Coshocton County OSU Extension 724 S. 7 th Street, Room 110 Coshocton, OH 43812

3 4-H Camp Ohio Agricultural Extension Camps Inc Camp Ohio Road St. Louisville, Ohio Office Fax Camp & Bed Bugs: Pac cking for Prevention Whether they come to camp every year or this is their first trip, attending camp is an exciting time for children. Making new friends, exploring nature, and trying new things are all part of the camp experience and create memories that will last a lifetime. However, along with all the good parts of camp, a pesky little bug can also be part of the experience. In recent years, bed bugs have made a resurgencee in North America. They are often found in hotels, multi unit dwellings, and other structures that house people for short periods of time, such as camps. While bed bugs may be a nuisance, they do not transmit disease to people. The good news is that theree are simple steps that can be taken to help ensure that children do not bring bed bugs to camp or back home. We are taking proactive steps in our camp facilities, please help us by following the packing advice listed below: PACKING FOR CAMP Visually inspect items for bugs. Take sleeping bags, blankets, and luggage out of storage, place them outdoors, and inspect them carefully for any signs of bugs or eggs. Tumble bedding and lugg gage in clothes dryer. Place bedding or luggage in the clothes dryer and tumble them on a high heat setting for 30 minutes. The heat from the dryer kills bed bugs and eggs. For items that cannot be placed in a dryer, place into a black plastic garbage bag, then put it out in the hot sun for a day(s) as heat can kill this pest. Use a heavy gauge garba age bag as a liner in luggage. Place all clothing inside the liner and tightly twist and knot to seal. This will help keep bed bugs out of clothing. In addition, place bedding in a separate garbage bag. Duffle bags are recommended as luggage for campers as they can be placed in a dryer. Additional recommendation is keeping luggage closed when not in use. Rubbermaid container is also an option. Pack extra garbage bags. Be sure to pack two extra garbage bags for your child. One bag will be used for all dirty clothing and the other will be used for dirty bedding. Page 1 of 2

4 COMING HOME FROM CAMP Inspect items before you bring them indoors. Inspect items that cannot be placed in a washer/dryer for evidence of bed bugs outdoors and clean if necessary before bringing them indoors. Place bedding and clothes stored in garbage bags directly into the washer/dryer. Dispose of the plastic bag outdoors. Clean all camp items. For items that can be laundered, use a hot water setting and tumble dry on high heat for at least 30 minutes. For items that cannot be laundered, such as suitcases, vacuuming and place into a black plastic garbage bag, then put it out in the hot sun for a day(s) as heat can kill this pest. Wipe off shoes. Use rubbing alcohol to wipe off the bottoms of shoes H Camp Ohio s Procedure for Prevention: Cabins checks for bugs are performed immediately after a group departs as part of our normal cabin sweep procedures. The inspection is performed by the company Four Paws K9 Detection. CimeXa dust is professionally applied on each bed and cabin as routine treatment. This is to prevent bugs being brought into the cabins and laying eggs. If any signs of bed bugs are found during inspections, after a group has left, we immediately contact our extermination company for an additional inspection and treatment. Please do not n bring b and apply store bought spra rays as they can dilute or wash away the CimeXa dust leaving an a untreated area. If during a stay a guest believes to have found signs of bed bugs we immediately collect all clothing, luggage and bedding from the cabin and heat using laundry dryers to kill any bugs that may be in the guests belongings. If possible we then move the group to another cabin. If you have any further questions, please feel free to contact us. Anthony Imbody Executive Director 4-H Camp Ohio Page 2 of 2

5 STAY IN TOUCH THIS SUMMER WITH BUNK NOTES We are excited to tell you about our continued partnership with Bunk1, allowing you to send Bunk Notes throughout the summer. Using a secure login, you ll be able to send a Bunk Note to your camper at any time of the day and it will be delivered with the regular mail the very next day. No need to wait for USPS to deliver - Bunk1 makes it easy to communicate with your child! Please note: Bunk1 is not owned and operated by 4-H Camp Ohio. This is a service that 4-H Camp Ohio subscribes to. Problems with payment or sending of needs to be directed to Bunk1 and not 4-H Camp Ohio. It is strongly recommended NOT to send an the day the camper leaves camp, the camper may not receive the . All is printed in Black and White, not color. RETURNING PARENTS GET STARTED TODAY! NEW PARENTS Go to Enter your address and password in the space provided. NOTE: - You are logging into the same account that you used last year. If you have forgotten your summer password, click Need to reset your password? You will be prompted to enter your address and will be sent a link to reset your password. If you do not receive an , please also check your spam folder. Go to Click the link for Need an Account or have an invitation code Complete the basic form to create your account. You will be asked to enter an Invitation Code. Please use the following code: VESPER1928 NOTE: - For your camper s safety, please do not share the invitation code above. SENDING BUNK NOTES Step 1: Purchase a Bundle or Bunk Note Credits. A Bunk Note Credit costs $1 and packages of various sizes are available. You have the option to enhance your Bunk Note by attaching photos, adding baseball box scores, Sudoku Puzzles, borders, or twitter feeds. Please note that adding these features will utilize additional credits. Step 2: Send your note. Select your camper s name and the correct cabin, type in your message, then hit the Send Bunk Note button. Every 24 hours, camp will receive a pre-sorted PDF of all the sent Bunk Notes. FREQUENTLY ASKED QUESTIONS: Can other relatives use these services? Absolutely! As soon as you login, you will notice a button under the heading Quick Links to Invite Family Members. Click that button, enter their details and they will be sent an . PLEASE NOTE: this will prompt them to set up their own account. It does not provide them access to your account OR your Bunk Note Credits. Accessing Bunk1 from a mobile device? The Bunk1 website is mobile optimized. For your convenience, add our Bunk1 icon to your iphone home screen. To do so, open Safari, go to then tap the Share button (blue square with an arrow pointing upward on the toolbar). Tap Add to Home Screen and Bunk1 will be as accessible as your native apps! Questions or Problems? Please call Bunk1 at or support@bunk1.com Google Chrome is the preferred web browser for using the Bunk1 System. You can download Google Chrome for free by visiting:

6 Ohio 4-H Health Statement Participant/Member Information: OHIO STATE UNIVERSITY EXTENSION ALL SIDES of this form MUST be completed for each participant. Minors must have the form completed and signed by a parent/guardian. This information will be kept confidential and used only for the welfare of the participant. PRINT neatly using blue or black ink. Name: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip) REQUIRED! Attach Picture (for I.D. purposes only) Home Phone: County: Date of Birth: Male/ Female Age (today): Emergency Contact Information: Parent/Guardian Name: Other Contact/Relationship: Other Contact/Relationship: Physician: Dentist: Parent/Guardian Cell Phone: Other Cell Phone: Other Cell Phone: Physician Phone: Dentist Phone: Health History: Communicable Diseases: Provide the date (approximate is acceptable) at which participant has had or was exposed to: Chicken Pox Measles Whooping Cough Tuberculosis Mumps Other Communicable Diseases Immunization/Vaccine Record: To the best of knowledge, the participant is up-to-date on all immunizations which may include, but is not limited to: Diphtheria/Pertussis (Whooping Cough-TDAP), Polio, Measles/Rubella/Mumps (MMR), Haemophilus Influenza (HIB), Varicella (Chickenpox) that are required for school. The participant has received a Tetanus Booster. Date of last booster: If the participant is not current or up-to-date with immunizations, please complete the Ohio 4-H Immunization Exemption Form. Medical Instructions: Medications/Allergies, Current/Past Medical Conditions: Current Medications (Prescribed and Over-The-Counter, Current or Past Medical Treatment): (please list additional medications or needs on a separate sheet) Name of Medication: Dosage: Frequency/Instructions: ohio4h.org CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For more information: go.osu.edu/cfaesdiversity.

7 Last Name First Check below if the participant is subject to any of the following conditions: Asthma Controlled? yes/no Acetaminophen ( ex: Tylenol) Bronchitis Cramps Fainting Heart Trouble Seizures Sore Throat Athlete s Foot Constipation Diarrhea Frequent Colds Home Sickness Sinusitis Other? Bed Wetting Convulsions Ear Infections Headaches Kidney Trouble Sleep Walking Allergies: If none, please write NONE here: Food allergies: Medication allergies: Serious Ivy, Oak or Sumac Poisoning: What is the prescribed treatment? Serious bee or insect sting reactions: What is the prescribed treatment? NOTE: If participant s allergy may require use of an EPI-PEN, then the participant must provide the Epi-Pen(s) and discuss possible administration with health care professional upon arrival to camp. Accommodations for Camp: Please tell us about the accommodations your child may need at 4-H camp: I will be bringing medications to camp (please describe whether they require refrigeration or special storage below). I have dietary restrictions (describe below). I have limited mobility (e.g. crutches, cane, etc.). I have ADHD or a related attention deficit disorder; a visual, hearing, cognitive processing, reading, or a speech impairment. (describe any needs you anticipate at camp and the accommodations you typically receive at school and home below). I require the use of medical equipment that needs electricity (describe below). I require other accommodations not listed above (describe below). I do NOT require any special accommodations (none of the above apply to me). Description of any past or current physical, mental, or psychological conditions requiring medication, treatment, or special restrictions or considerations while at camp: Description of any camp activities from which my child should be exempted for health reasons: Instructions for Medications: All prescription drugs must be carried in the container in which they were issued (with medical orders and physician s name intact) and given to the nurse/health director. Other prescription drugs will not be accepted. Only bring the amount needed for your stay at camp. If you need regular over-the-counter medications, they must be in the original container. Like prescription medications, these medications must be given to the nurse/health director. All medications will be given as directed on the original package/container. If there are any dosage adjustments, you must bring signed documentation from your physician. Check medication(s) that participant may receive if deemed necessary and administered by a health professional. Examples of brand names are given in parentheses. Generic or other name brands may be provided: Antibiotic Ointment (ex: Neosporin) Dramamine Aloe Lotion Cough Syrup/Drops Ibuprofen (ex: Advil, Motrin) Poison Ivy Medicine (ex: Calamine Lotion) Sore Throat Medicine Antacids (ex: Maalox, Tums) Decongestant (ex: Sudafed) Insect Repellent Sun Screen Antihistamine (ex: Benadryl, Claritin) Diarrhea Medication (ex: Imodium) Laxative (ex: Milk of Magnesia) Swimmer s Ear Medicine Antiseptics

8 Last Name First Emergency Medical and Informed Consent/Camp/Program Release I understand that my child, will be a participant in the Ohio 4-H program and I grant permission for him/her to participate in this program and associated activities with the exception of any restricted activities that I have listed below. I understand that my child is not required to participate in this program, but grant my permission for him/her to do so, despite the potential risks. I recognize that by participating in this program, as with any physical activity, my child may risk personal injury, paralysis and/or death. I understand program participants will be supervised and acknowledge that the 4-H staff and volunteers, OSUE, The Ohio State University, and the 4-H Camp Site are not responsible for any potential injury or illness resulting from my child s participation. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved and that I assume any expense that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. I understand that most program activities are conducted outdoors and that wearing proper dress (e.g., rain gear, warm clothing) is an essential part of the camp safety rules and procedures. I am aware of and have discussed with my child the established safety rules and procedures. In the case of serious illness or injury of my child, I understand that I will be notified. If I cannot be contacted, unless otherwise specified below, I grant permission to the attending medical professional to secure proper treatment, hospitalize, and/or take any other action deemed necessary for the immediate care of my child. In consideration of the opportunity for my child to participate in this program, I, acting for my child, myself and our respective heirs, executors, administrators and assigns, agree to assume any and all risks associated with this activity and do hereby release, indemnify and hold harmless The Ohio State University, its Board of Trustees, OSUE, the Ohio 4-H program, the 4-H camping facility, and their respective officers, agents, and employees from any and all liability, damage, and/or claim of any nature resulting from or arising out of my child s participation in this program and its activities. Restricted activities and/or special notification instructions:. Photo and Video Release I give permission to The Ohio State University, OSUE, the Ohio 4-H program, and the 4-H camping facility to record and edit into video and/or photographs the likeness, voice, image and video images of my child,, and to use all or parts of the video or photographs in print or electronic materials for The Ohio State University, OSUE, the Ohio 4-H program, and 4-H camping facility to promote any and all public awareness for the program(s) in which my child is involved. Parent/Guardian Printed Name Parent/Guardian Signature Date CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For more information: { } Bloir, K., Epley, H.K. Updated 8/2016

9 has my permission to participate in the Ohio 4- H program and activities as listed on the 4- H Camp Ohio website (with the exception of any restricted activities listed previously). I understand participants will be supervised. I understand the 4- H staff and volunteers; The Ohio State University Extension and The Ohio State University are not responsible in the event of accidental injury or illness, or for the compounded injury or illness to the participant s present medical conditions listed. I understand 4- H Camp Ohio is not liable for uncontrollable circumstances such as communicable diseases or infestations including but not limited to bed bugs and lice. I further understand in case of serious injury or illness I will be notified. I understand my child is not permitted to have a cell phone in their possession during their stay at camp. Parent/Guardian Signature: Date: