4-H CAMP 2017 COST. GO ONLINE All 4-H Camp forms, schedules and other information can be found on our website: DATE and LOCATION

Transcription

1 4-H CAMP 2017 Dear Parent/Guardian and Camper, Hello from 4-H! The attached form is to reserve your spot for the 2017 Breathitt County 4-H Summer Camp! Please get this form back to me AS SOON AS POSSIBLE because our SPACE IS LIMITED this year. The 4-H staff looks forward to a terrific camp season for 2017! If you have any questions you can contact myself at Sincerely, Jessica L. Ritchie CEA for 4-H Youth Development Age Requirement CAMPER: Ages 9-14 Jessica A. Gross 4-H Program Assistant JR. COUNSELOR: Age 15 SR. COUNSELOR: Ages ADULT COUNSELOR: Age 18+ (Contact the Extension Office for Counselor Applications) TO REGISTER Complete the attached form and return to: Breathitt Co. 4-H Camp, P.O. Box 612, Jackson, KY or return it to our office at 1155 Main Street. PLEASE COMPLETE ENTIRE FORM! DATE and LOCATION Thursday, June 22-Sunday, June 25, 2017 J.M. Feltner 4-H Camp, London, KY DEADLINES The registration deadline is Friday May 26, 2017 *Camp sessions are filled on a first come, first serve basis, so don t delay! If the spots fill up, we will begin a waiting list if spots become available. COST $60.00 (Includes transportation, 3 nights lodging, 12 meals, 2 snacks per day, class fees & t-shirt) ALL FEES MUST BE PAID BY MAY 26 *Ask us about a payment plan Payments Accepted: Cash or Check (made payable to Breathitt Co. 4-H) Both first-time and returning campers, along with a parent/guardian, are required to attend a CAMPER ORIENTATION on Thursday, June 8 5:30 p.m. at the Breathitt County Extension Office. Unless otherwise notified, your attendance at this orientation will confirm that you are still attending camp. GO ONLINE All 4-H Camp forms, schedules and other information can be found on our website:

2 Kentucky 4-H Camping Program 2017 Camp Participant Registration Adults Volunteers (Age 18+) Last Name: Legal First Name: Middle Name: Preferred Name: Attended camp before? Yes - # years: No Birthdate: / / Gender: M F Participant s home address: Race (check all that apply) American Indian Asian Pacific Islander White Black Hispanic Non-Hispanic Emergency Contact: Full Name: Relationship to participant: Cell/Home Phone: Medication Allergies (list all known) Reaction & Management: Food Allergies and Dietary Restrictions (list all known) Reaction & Management: Other Allergies (list all known) Reaction & Management: Tetanus: As part of the accreditation requirements for American Camp Association, participants must provide camp with the date (month and year) of the most recent tetanus shot/booster. Date of most recent tetanus shot/booster (Month/Year): / *REQUIRED* Medical Things you should know: 1. In case of an emergency, we will call the local ambulance service. It takes at least minutes for an ambulance to get to camp. At the Lake Cumberland location, response time will be minutes. 2. During your stay, the Camp Health Care Provider (who will be a certified EMT or Nurse) is available to help with your emergent health needs. 3. Our camps have an AED and portable oxygen onsite. 4. All medications must be given to the Health Care Provider (HCP) upon arrival at camp for secure storage or placed in a locked area to be non-accessible to others. 5. There is a clinic/hospital available to you nearby, if needed. CAMP USE ONLY: Health History reviewed by camp medical personnel on:

3 AUTHORIZATIONS/RELEASES This is a legal document. You must read and understand it before signing it. Medical Consent and Vehicle Usage: I have read the information both on this page and in what was sent to me as an adult participant for the camp program. I understand my health information will be shared with camp medical staff and that, as an adult, I retain primary responsibility for managing my health status while at camp. I agree to inform the camp of any changes that might impact my participation. I grant permission for use of my personal vehicle, if needed. In doing so I state that I have an adequately maintained vehicle, maintain insurance in compliance with state laws and carry basic safety equipment. Adult Participant Signature: Date: Media Release: I grant the Kentucky 4-H Program and the University of Kentucky, and persons acting through them, the right to use, reproduce, assign and/or distribute photographs, films, videotapes, and sound recordings of me without compensation for use in promotion/advertising, educational publications, electronic publishing, and personal memorabilia. Participant names may be published. Adult Participant Signature: Date: Assumption of Risk and Release from Liability: I acknowledge that there are certain risks, hazards, and dangers, including the risk of physical injury, disability, or death and risk of loss of use or damage to my personal property as a result of 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/or adequate emergency medical care. I understand that the University of Kentucky does not guarantee the personal health or safety for participants, nor does it protect against the risk of loss of personal property. In consideration for participating in the camping program, I do hereby release Kentucky 4-H Camp, the University of Kentucky, and its members, trustees, officers, employees, independent contractors, volunteers and extension staff from any and all liability, damages, cost and expenses arising out of or relating to bodily or psychological injury, loss of life, or personal property that may occur as a result of participating in the camping program. Adult Participant Signature: Date:

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

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

6 Fanny Pack Water Bottle Sunscreen NEW FOR 2017 CAMPER PACK $20.00 Pre-order your Camper Pack for $20.00 with your camp registration. The camper pack is valued at over $28.00 and includes everything listed! With lots of room for all your camp gear, every camper will want the Camper Pack! Ask your county agent for more information or to see a sample Camper Pack! Hand Sanitizer T-Shirt Flashlight Lantern Camp Bracelet Limited quantities and some items may be substituted without notice. YES! I WANT ONE! CAMPER NAME