4-H Extension Educator 4-H Extension Educator

Transcription

1 December 2017 Dear 4-H er and Potential Camp Counselor: Thank you for your interest in the H Camping Program! You can be part of the camping program by being selected as a 4-H Camp Counselor. While your involvement with the program would be a privilege and responsibility for you, we too would be privileged to have you as part of the team! A reminder that everyone wanting to be a camp counselor must be at least 14 years old by the start of camp, needs to submit an application, signed Standards of Behavior Form, signed Code of Conduct Form, Counselor Permission to Participate 2018 Fairfield County 4-H Camps, Ohio 4-H Health Statement Form, provide two references (due by January 5), and completed a project in 2017 regardless of whether you are a returning counselor or a new counselor. A complete list of requirements is included in the Camp Counselor Job Description included in this Application Packet. Also in this Camp Counselor Packet, please notice this year s training schedule. We will again be offering an Intermediate, Junior, and Cloverbud Camp! It is very important for all Camp Counselors to be in attendance at all trainings. Attendance will be required 100% of the time (no one will be permitted to leave early or arrive late) in order to counsel this year. New for 2018: Cloverbud Counselors will be on a different training schedule this spring (than those serving as Junior and Intermediate Camp Counselors) and Cloverbud Counselors will only need 12 hours of training prior to Cloverbud Camp. The enclosed job opportunity announcement lists the counselor training dates, states the requirements needed to be a counselor, and describes the responsibilities of a counselor. Please mark these dates on your calendar now so that you can be sure to attend. If you do have to miss a meeting, notify us in advance so we can discuss options for continuing on in the counselor selection process. Otherwise, failure to attend a training or planning meeting will prohibit you from counseling at camp this year. As the same in years past, final selections will not be made until after we have completed the first few trainings and planning meetings. Because changes have been made to the camps offered for Fairfield County, and we have a significantly higher number of counselors interested in working at camp this year, we may not be able to offer everyone an opportunity to counsel at camp. Decisions will be made on the basis of past performance and participation in trainings and planning meetings. As a 4-H member interested in camp counseling, we are also extending to you two additional opportunities! One is attending the State Counselor Making extreme Counselors Training February 17-18, 2018 and the second is attending the Ohio 4-H Conference March 10, These are both unique ways to improve your skills as a camp counselor and learn from other counselors throughout the state. Attending these opportunities can help cover missed training hours due to conflicts with regular county trainings, however these two opportunities DO NOT REPLACE the training required at the county level. Cost of the training and conference is to be determined, but shouldn t exceed more than $50 for training and $35 for the conference which includes meals and any materials. If an Ohio 4 - H Achievement Form is completed, the fee will be reduced for the Ohio 4-H Conference. If you are interested in the Ohio 4-H Conference, registration forms will be available at the Extension Office and are due by February 2 nd, If you have any questions, please call Leslie at or cooksey.25@osu.edu. I d also like to introduce our second 4-H Extension Educator and his contact information Boone Troyer! He will be the point of contact for all Junior and Intermediate Camp Counselors/Camps and I will be the point of contact for Cloverbud Counselors/Camps. Boone s contact information is or troyer.139@osu.edu. We look forward to an awesome year of Fairfield County 4-H Camping in 2018! Sincerely, College of Food, Agricultural and Environmental Sciences Ohio State University Extension - Fairfield County 831 College Avenue, Suite D Lancaster OH Phone Fax fairfield.osu.edu Leslie S. Cooksey Boone Troyer 4-H Extension Educator 4-H Extension Educator Enclosure: Camp Counselor Application Packet

2 OHIO STATE UNIVERSITY EXTENSION EVENT/OPPORTUNITY: 4-H Camp Counselor DATE / DEADLINE: Applications are due to the OSU Extension Office by 4:000 p.m. on Friday, January 5 th, LOCATION of PROGRAM: Tar Hollow State Park, Laurelville, Ohio for Junior and Intermediate Camps and Alley Park, Lancaster r, Ohio for Cloverbud Day Camp. PROGRAM DESCRIPTION: The 4-H Camp Counselors are a group of 4-H teens selected to assist in being responsible for campers ages (Intermediate Camp), ages 8-10 (Junior Camp) and ages 5-8 (Cloverbud Camp) during 4-H camp. As a result of participation, counselors will develop knowledge, skills, attitudes and aspirations needed for adult success, and the Fairfield County 4-H Program will be strengthened and expanded. Roles and Responsibilities of 4-H Camp Counselors include: Attend required trainings prior to camp. Market and promote camp. Serve in a leadership and teaching role to other counselors. Serve on a team or other groups to plan and implement programs at camp. Conduct self in an appropriate manner before, during, and after camp while serving as a role model to campers and peers. Assist staff and other counselors with camp activities; work as a team to implement the activities. Know and understand all safety guidelines, including emergency procedures, associated with the camp and program areas. Follow and enforce camp rules. Assure the safety of campers at all times including in cabins, sessions, and large group activities. Be aware of child protection regulations and report any childd abuse, sexual abuse, or neglect in accordance with university policy. Identify and respond to camper behavior issues. Ensure campers health and hygiene, e.g., brushing teeth, eating meals, taking medication, etc. Promote camper participation during camp. Lead and supervise campers in activities at camp including but not limited to songs, teambuilding challenges, group activities, games, challenges, etc. Teach and lead campers at workshops or during other components at camp (crafts, line dancing, canoeing/kayaking, table setting, camp clean-up, song leading, etc.). Mentor and give guidance to campers to encourage positive youth development and enhancement of life skills. Be on time at meals, workshops, sessions, and activities. One counselor must sleep in a bed next to the cabin door (only applies to Tar Hollow Intermediate and Junior Camps). REQUIREMENTS: Must be a 4-H member in good standing. Must be at least 14 years old by the start of camp. Must be able to get transportation to and from meetings and events as needed. Junior and Intermediate Camp Counselors must complete a minimum of 24 hours of training (6 of these hours must be onsite at Tar Hollow) Cloverbud Camp Counselors must complete a minimum of 12 hourss of training (2 of these hours must be onsite at Alley Park). Must complete Child Abuse Awareness training. Must Sign Standards of Behaviors, Code of Conduct, Counselor Permission to Participate Fairfield County 4-H Camps, and have a current Ohio 4-H Health History form on file. Applicants must provide two references (with at least one completed by your 4-H Advisor). If the individual is 18+ year old at least two months prior to camp, the individual must have their background check conducted. SELECTION PROCESS: Individuals who complete the application and fulfill application requirements will be contacted regarding the selection process. fairfield.osu.edu CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For more information: go.osu.edu/cfaesdiversity.

3 OHIO STATE UNIVERSITY EXTENSION UPDATED 12/15/2017 JUNIOR & INTERMEDIATE CAMP COUNSELORS MEETING DATES/TIME/FREQUENCY JUNIOR and INTERMEDIATE Camp Counselors are REQUIRED to meet the following dates throughout the year. January 20 th Ag Center 9:00-11:00 a.m. *Interviews and Selection *New counselors and returning counselors starting their second year February 6 th Ag Center 6:00 8:00 p.m. *New Counselor Orientation *New counselors and returning counselors starting their second year February 19 th Rickett s Hall Fairgrounds March 14 th Ag Center 6:00-7:00 p.m. 7:00-8:00 p.m. 8:00-9:00 p.m. April 11 th Ag Center 6:00-7:00 p.m. 7:00-8:00 p.m. 8:00-9:00 p.m. April 25 th Ag Center 6:00-7:00 p.m. 7:00-8:00 p.m. 8:00-9:00 p.m. 12:30-5:00 p.m. Program Planning for Junior & Intermediate Camp Counselors Program Planning: Intermediate Camp Teams Training: All Camp Counselors Program Planning: Junior Camp Teams Program Planning: Intermediate Camp Teams Training: All Camp Counselors Program Planning: Junior Camp Teams Program Planning: Intermediate Camp Teams Training: All Camp Counselors Program Planning: Junior Camp Teams May 11 th - 12 th TBA 6:00 p.m. Counselor Training Overnighter Overnighter will conclude at 12:00 p.m. on Saturday, May 12 th May and June - Additional Camp Planning for Teams as needed! May 24 th Ag Center 5:30-7:30 p.m. 4-H Camp Round-up 4:30-6:15 p.m. Shift #1 for Counselors to work Camp Round-up 6:15-8:00 p.m. Shift #2 for Counselors to work Camp Round-up June 12 th June 25 th Tar Hollow Laurelville, OH Tar Hollow Laurelville, OH TBA Tar Hollow Counselor s Camp (Cost TBA) Required for all Junior and Intermediate Counselors 3:00-4:30 p.m. Fairfield County Intermediate Camp Staff and Counselor Move-In June 26 th - 29 th Tar Hollow Laurelville, OH Fairfield County Intermediate Camp July 6 th Tar Hollow Laurelville, OH 3:00-4:30 p.m. Fairfield County Junior Camp Staff and Counselor Move-In July 7 th - 10 th Tar Hollow Fairfield County Junior Camp Laurelville, OH July 25 th Ag Center 6:00-7:30 p.m. Counselor Fun Night Counselors are expected to notify the Extension Office if an absence is unavoidable.

4 OHIO STATE UNIVERSITY EXTENSION UPDATED 12/14/2017 CLOVERBUD CAMP COUNSELORS MEETING DATES/TIME/FREQUENCY CLOVERBUD Camp Counselors are REQUIRED to meet the following dates throughout the year. January 20 th Ag Center 9:00-11:00 a.m. *Interviews and Selection *New counselors and returning counselors starting their second year February 6 th Ag Center 6:00 8:00 p.m. *New Counselor Orientation *New counselors and returning counselors starting their second year February 19 th Rickett s Hall Fairgrounds 9:00 a.m. - 12:00 p.m. Program Planning for Cloverbud Camp Counselors April 5 th Ag Center 6:00-8:00 p.m. Program Planning and Training: Cloverbud Camp Counselors May 2 nd Ag Center 6:00-8:00 p.m. Program Planning and Training: Cloverbud Camp Counselors May 23 rd Ag Center 6:00-8:00 p.m. Program Planning and Training: Cloverbud Camp Counselors May and June - Additional Camp Planning for Committees as needed! May 24 th Ag Center 5:30-7:30 p.m. 4-H Camp Round-up 4:30-6:15 p.m. Shift #1 for Counselors to work Camp Round-up 6:15-8:00 p.m. Shift #2 for Counselors to work Camp Round-up May 30 th Alley Park 6:00-8:00 p.m. Picnic, Onsite Training and Final Planning: Cloverbud Camp Counselors June 9 th Alley Park 9:00 a.m. 4:00 p.m. Cloverbud Day Camp July 25 th Ag Center 6:00-7:30 p.m. Counselor Fun Night Counselors are expected to notify the Extension Office if an absence is unavoidable.

5 OHIO STATE UNIVERSITY EXTENSION MEETING DATES/TIME/FREQUENCY (continued): 4-H Camp Counselors can optionally participate in the following Camp Counselor Training Opportunities in 2018: Making extreme Counselors on February 17 th & 18 th, 2018 (time to be announced) at the Nationwide and Ohio Farm Bureau 4-H Center in Columbus, Ohio. Separate registration information must be completed and there will be a fee (amount to be determined) for this training to be paid by the Camp Counselor. MXC Registration will be due to the OSU Extension Office on Friday, January 26 th, Ohio 4-H Conference on March 10 th at the Columbus Convention Center in Columbus, Ohio (time to be announced). Separate registration information must be completed and there will be a fee (amount to be determined) for this training paid by the Camp Counselor. If the Ohio 4-H Achievement Form is completed, part of this fee will be reduced for the Ohio 4-H Conference. Ohio 4-H Conference Registration will be due to the OSU Extension Office on Tuesday, February 2 nd, Counselors are expected to notify the Extension Office if an absence is unavoidable. SUPERVISOR: 4-H Camp Counselors report directly to the Camp Director with supervision by the entire camp staff. BENEFITS: Develop leadership skills, gain self-confidence, assist in personal development of younger 4-H members, meet new friends, reduced camp fees. TO APPLY: Complete the application packet in its entirety. Turn in completed reference forms from two non-family members (one must be completed by your 4-H Advisor). Read, sign, and return your Application. Read, sign, and return your Standards of Behavior Form. Read, sign, and return your Camp Counselor Code of Conduct Form. Read, sign, and return your Counselor Permission to Participate Fairfield County 4-H Camps Form. Read, complete, sign, and return your Ohio 4-H Health Statement (with picture attached). Return all materials to the Fairfield County Extension Office by Friday, January 5 th, 2018 at 4:00 p.m. (no exceptions).

6 OHIO STATE UNIVERSITY EXTENSION FAIRFIELD COUNTY 4-H CAMP COUNSELOR APPLICATION Name Age (January 1, 2018) Date of Birth (00/00/0000) Home Address (Street) (City) (State) (Zip) Home Phone Cell Phone Is texting an option? (circle) Yes No 4-H Club Years in 4-H School Attending: Grade in School In case of injury or accident, notify: Name Relationship Phone 4-H Project Experience: What 4-H project(s) did you take and complete last year (2017)? This does not include any FFA or other school or community projects taken. Please note it is required to complete a 4-H project a year prior to counseling at 4-H camp! Basic Camp Information: Years attended 4-H Camp as a Camper Years as a 4-H Camp Counselor Why do you want to be a Camp Counselor? What traits, skills, or special experiences do you have that would benefit you in this position? (Please include experiences working with children and youth.) What skills or contributions will you add to the counselor team in making sure camp is successful? (such as First Aid, Babysitter s Course, Recreation, etc.) 3 words that a friend would use to describe you:

7 List and describe a leadership experience you have had: OHIO STATE UNIVERSITY EXTENSION What hobbies and/or special interests do you have that you would like to share? Please list 2 of your strengths: Please list 2 of your weaknesses: Each year the counselors and adult staff select a timely and fun camp theme and plan the camp activities and programs around the theme. Using a camp theme you would suggest, complete the following camp plan. (The themes listed will be the themes discussed at the planning meetings.) CAMP THEME: SUGGESTIONS FOR PROGRAM IDEAS REGARDING THIS THEME (Group Names, Guest Speakers, Activities, etc.): Camp Planning Information: Please mark your preference on the camps you would like to be considered to counsel at. Please select up to one option for each section. (Make sure you are age eligible before selecting!) Section 1 Section 2 Intermediate Camp Only (must be 15 years old as of 6/25/2018) June (Counselors & Staff will come June 25) Junior Camp Only (must be 14 years old as of 7/6/2018) July 7-10 (Counselors & Staff will come July 6) Intermediate Camp AND Junior Camp (I would like to counsel at both camps, if possible) Intermediate Camp OR Junior Camp (I do not have a preference, but I only want to counsel at one of the camps) Intermediate Camp and Junior Camp if you need me (I will assist at both camps, but only if necessary) Cloverbud Day Camp Counselor June 9 (must be 14 years old as of 6/8/ will work with campers day of camp) Cloverbud Day Camp Workshop Leader June 9 (must be at least a 2 nd year counselor in will lead a workshop during camp)

8 OHIO STATE UNIVERSITY EXTENSION Counselor Permission to Participate Fairfield County 4-H Camps I give permission for my child (name) to participate in Fairfield County 4-H Camp(s) at OSU Extension/Ohio 4-H Center/Tar Hollow State Park/Alley Park on (circle dates) May 11-12, May 30, June 9, June 12, June 25, June 26-29, July 6, July Activities involved in camp will include living in a cabin on a hill; sharing bathroom facilities with other campers on the hill; sleeping in bunk beds; canoeing and swimming in a pond; nature hikes; playing volleyball, basketball, relay races and other recreational games; campfire activities; and dances. Attending 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 not a requirement for 4-H membership. I am aware, and have discussed with my child, that: A. Being in and around water, woods, and participation in camp activities may cause clothing to become wet, dirty, and beyond cleaning and/or repair; B. While in a canoe, my child may be involved in a collision with another canoe, person, or object in the water; C. Hiking may give rise to risk of injury arising from the surface or subsurface of the ground on which the hiking occurs; D. Participation in sporting/recreational events may give rise to injury as a result of collisions with another individual or sudden falls; E. Other participants may act in a negligent manner which otherwise may result in harm to my child; F. Swimming in a pond 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 risks 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 the possible risks. 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 the 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. Fairfield County 4-H Camp Rules 1. Report all sickness & injuries to the nurse at once. 2. No swimming or canoeing when the lifeguard is not present. 3. Shoes must be worn at all times (except when showering, sleeping or swimming). 4. No running on trails or hills. 5. Respect others and their property. Use language and manners that are respectful. 6. No fighting. 7. Remain in your own cabin. No one is permitted on hills during program, recreation, campfire, etc. time. No one is permitted on a hill other than their own. 8. Everyone must be in their cabin and quiet by lights out, and remain there until 6:30 a.m. Quiet hours are from lights out until 8:00 a.m. If you are someplace other than in your cabin, the bathroom, or the nurse s station after lights out, you will be sent home. 9. A raised hand means to listen. When you see someone with a raised hand, you also raise your hand, be quiet and listen for instructions. Be quiet when appropriate and help keep campers quiet. 10. State law prohibits possession of alcohol, drugs, fireworks, and firearms at the state park. Tobacco products are also not permitted at camp. Anyone is possession of such items will be immediately sent home. The park ranger will also be notified. I understand and have explained to my child the behavior that is expected during their participation in the Fairfield County 4-H Camp. I also understand and have explained to my child that not following the above stated rules may require them to call me to explain their behavior and pick them up from camp. Signed (Parent/Guardian) Date Signed (Counselor) Date

9 OHIO STATE UNIVERSITY EXTENSION Ohio 4-H Camp Cell Phone Policy (Ohio 4-H Policy effective October 2015) As a means of risk management, youth participants (campers and counselors) may not possess cell phones* during 4-H camp. Counselors shall not use cell phones (as alarms, music players, etc.) in their cabins at any time. Camp Program Directors have discretion for permitting camp counselors selective cell phone use during limited time periods, such as during out-posting, nature treks, or off-camp travel (field trips), or for other safety concerns where the use of two-way radios is not practicable. Camp Program Directors will determine consequences for possessing a cell phone. The State 4-H Office recommends a zero tolerance approach: If an individual is caught with a prohibited cell phone, they will be sent home at the family's expense. *Camp Program Directors also have discretion for prohibiting other internet-enabled devices at their 4-H camps. The Fairfield County Camp Director recognizes the Ohio 4-H Camp Cell Phone Policy. However, Fairfield County Camps will abide by the Tar Hollow Electronics Policy as we will prohibit other electronic devices as outlined below: TAR HOLLOW ELECTRONICS POLICY FOR CAMPERS AND COUNSELORS (Approved by the Ross Hocking Extension Camp Board 3/27/2014) Cell Phones: Campers and counselors shall NOT bring any kind of cell phone to camp. Cell phones do not have reception at camp, and their use as cameras is prohibited. Music players: Counselors and staff may bring music players, radios, and ipod type devises but only for use in the cabins as alarm clocks and for music. Counselors may use ipod type devices outside of the cabin only at dances where the counselors are serving in a DJ capacity. In addition ipods may not be used to play games or in a cell phone like capacity for texting, photos, or internet purposes. Other electronics: Campers and counselors shall NOT bring any other handheld game, laptop, or other communications devices capable of accessing the Internet through Wi-Fi or another external network. Cameras: Campers may bring cameras to camp provided that they cannot upload pictures to the Internet. Due to the nature of camp programs, a disposable or inexpensive camera is highly recommended. MESSAGE TO PARENTS: We know in this high-tech era that it s difficult for youth to not be in constant contact with their families and friends via Facebook, texting, or cell phone calls. However, camp is a unique experience. The camp experience helps youth develop life skills including independence and self-reliance. Among the concerns that make bringing and using cell phones and other communication devices inappropriate at camp are: Concern that such expensive devices will be lost, damaged, or stolen. OSU Extension, camp, and staff cannot accept responsibility for lost, stolen, or damaged items at camp. Inappropriate use of photo and video devices. We know from media reports that the ease of uploading inappropriate photos and videos is a concern. Cyber bullying is not permitted before, during, or after camp. In addition, youth contact with home if they are suffering a temporary spate of homesickness at camp may cause the condition to worsen. We fully appreciate and respect the positive relationships our campers and counselors have with their families, but if they are to benefit fully from the camp experience, they must be encouraged to develop the skills of independence and self-reliance. If there is an emergency, or if we are concerned about the youth s well-being, we will contact the parents or guardians immediately. Campers are constantly in the company of other campers and counselors while at camp, and our camps are staffed with many caring adults, including an experienced camp nurse. Thank you for your cooperation with our electronics policy.

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11 OHIOO STATE UNIVERSITY EXTENSIONN 4-H CAMP COUNSELOR CODE OF CONDUCT I, agree that if selected, I will participate in the 4-H Camp Counselor Training Program. I understand thatt this is a training period and only once I complete my certification am I permitted to be a counselor at 4-H Camp. I understand that I am taking on a different role at camp. I am applying to serve others, not to go purely for my own enjoyment. By signing below, I acknowledge that I have read and agree to abide by the requirements, responsibiliti ies, and expectations listed in this application packet if selected as a camp counselor. I understand and agree thatt I will be asked to call my parents/guardian immediately to pick me up if I conduct myself in an irresponsible manner, which includes being outt of my cabin after hours and/or the possession or use of tobacco, alcohol, illegal drugs or fireworks. I will be expected to: Attend the required number of counselor training sessions. I understand I will be dismissedd if I am not able to complete the required training. Abide by the No Cell Phones at Camp Policy and Tar Hollow Electronics Policy. Treat other peers with respect. Not bully fellow counselors or participate in goat-play orr hazing. Conduct myself as a positive role model and be responsible. Set a good examplee by not using profanity or telling off-color tobacco, alcohol or illegal drugs. jokes,, and stories. As a 4-H member, not have in my possession Not have possession of harmful objects without specificc authorization from the camp director, including but not limited to: knives of any kind (pocket, utility, etc.), lighters, matches, fireworks, explosives, firearms, weapons, etc. No pornography or other sexually oriented materials including nudity in visual or written materials including similar content. Be a responsible cabin counselor and ensure campers are provided guidance towards a safe and fun week. Ensure that all campers are supervised by counselor staff at all times. Be sure that all campers know that they must remain on the camp grounds at all timess and are responsible for their behavior at all times. o Get to know each of the campers personally and by name. o Have all campers, including myself check in anyy of their medications with the nurse. o Make sure each camper uses personal hygiene. o Make sure that all of my campers are familiar with camp facilities and camp rules. o See that all campers are involved in all activities. Make sure no one is excluded. Check for illness or injury, but don't make much of a "fuss" about minor things. Go with hurt or sick campers to the nurse no matter how minor the ailment. Follow guidelines for lights out, and cabin supervision. Be in my cabin with my campers at all times between the hours of "Lights Out" and "Rise and Shine. Never discipline a camper by ridicule or physical punishment; patience and understanding works best. Urge safety at all times. Take time to explain how and why to do something safely. Work as a team to plan, organize and conduct all campp activities. Be flexible with counseling and adult staff (plans do change and rains do come). Participate in camp promotion. Follow leadership of camping program through adult advisors/volunteers/staff. Feel free to discuss problems with the Camp Director. I certify that the all the information being submitted is correct, and understand that failure to comply with these rules could result in probation, or loss of counseling position for the year. Applicant s Signature Date / / Parent/ Guardian Signature Date / / fairfield.osu.edu CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For more information: go..osu.edu/cfaesdiversity.

12 OHIOO STATE UNIVERSITY EXTENSIONN REFERENCE FORM is applying as a camp counselor at 4-H Camp this summer. The camp counselor selection committee would like your input about the qualities and ability to fulfill the responsibilities of a counselor. The information you include will not be shared with the applicant. Please complete this reference form based on your knowledge and/or observations. Thank youu for your help. 1. Please mark how you would evaluate the applicant s qualities, using this scale: Excellent Good Fair Poor Responsibility Communicationn skills Respect for others Dependability Enthusiasm Flexibility Patience Initiative Resourcefulness Ability to work with children (age 5-10) Ability to work with children (ages 11-14) Ability to work with other teens Ability to work with adults Not Known 2. Please write any additional comments here: Signed: Printed Name: Relationship to Applicant: Date: Please return no later than January 5 th, 2018 at 4:00 p.m. OSU Extension, Fairfield County Address: 831 College Avenue, Suite D, Lancaster, OH Fax: cooksey.25@osu.edu or troyer. 139@osu.edu Please note: Please submit in a sealed envelope. For questions contact the OSU Extension Office. fairfield.osu.edu CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For more information: go..osu.edu/cfaesdiversity.

13 OHIOO STATE UNIVERSITY EXTENSIONN REFERENCE FORM is applying as a camp counselor at 4-H Camp this summer. The camp counselor selection committee would like your input about the qualities and ability to fulfill the responsibilities of a counselor. The information you include will not be shared with the applicant. Please complete this reference form based on your knowledge and/or observations. Thank youu for your help. 1. Please mark how you would evaluate the applicant s qualities, using this scale: Excellent Good Fair Poor Responsibility Communicationn skills Respect for others Dependability Enthusiasm Flexibility Patience Initiative Resourcefulness Ability to work with children (age 5-10) Ability to work with children (ages 11-14) Ability to work with other teens Ability to work with adults Not Known 2. Please write any additional comments here: Signed: Printed Name: Relationship to Applicant: Date: Please return no later than January 5 th, 2018 at 4:00 p.m. OSU Extension, Fairfield County Address: 831 College Avenue, Suite D, Lancaster, OH Fax: cooksey.25@osu.edu or troyer. 139@osu.edu Please note: Please submit in a sealed envelope. For questions contact the OSU Extension Office. fairfield.osu.edu CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For more information: go..osu.edu/cfaesdiversity.

14 Participant/Member Information: OHIO STATE UNIVERSITY EXTENSION Ohio 4-H Health Statement 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.

15 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

16 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 Activity and Rules Release has my permission to participate in the Ohio 4-H program and activities as listed on the Tar Hollow 4-H Camp 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 Tar Hollow 4-H Camp 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 electronics in their possession during their stay at camp as per camp rules. 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