Agents for 4-H Youth Development Education Fayette County Fayette and Franklin

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1 Dear Parent/Guardian and Camper, Attached is the registration packet for the 2019 Fayette County 4-H Summer Camp! To add to our fun this year, we will be camping with Franklin County at J.M Feltner 4-H Camp, London, KY. It is sure to be Jungle Safari 4-H Camp! The 2019 camp will be Monday, June 17 - Friday, June 21, In this packet you will find all the information needed to register for summer camp. Please read this entire packet to ensure you are informed of all our changes this year. Upon receipt of the completed camp registration form and fee, you will receive a confirmation letter. A camper newsletter will be mailed prior to the mandatory camp orientation, which is being held on Monday, June 3, This newsletter will contain information on what to pack, departure day, medication form, pick-up on return day, and other reminders. The 4-H staff is looking forward to having a Jungle good time at camp! If you have any questions about 4-H summer camp, please contact us by (kevin.lindsay@uky.edu, madalyn.wells@uky.edu) or by telephone at (859) Kevin Lindsay Madalyn Wells Agents for 4-H Youth Development Education Fayette County Fayette and Franklin

2 Thank you for your interest in attending 4-H Summer Camp! We are excited for another great week this summer and are looking forward to you joining us! When: Monday, June 17, to Friday, June 21, 2019 Where: J.M. Feltner 4-H Camp 380 J.M. Feltner Road London, KY Who Can Attend Camp: All youth who have graduated 3rd grade are eligible to attend 4-H Camp in the summer of 2019 (typically age 9). Camper ages are 9 to 13. Priority will be given to Fayette and Franklin county youth. For youth ages 14 and older, please call the office for the appropriate camp registration form. Cost: Camper (9-13 years old) - $ Discounted Rate: If the completed camper registration packet is received in the FCES Office by 4:30 p.m. on March 1, $ Camp fee covers transportation to and from camp, meals (breakfast, lunch, dinner and one snack per day), class fees, and a t-shirt. (Camp fee does not cover the cost of any foods/snacks available for purchase at the Country Store.) Payment: Check or Money Order made payable to Fayette County 4-H Camp. To Register: Mail or drop off at the office the completed registration packet and fee to: Fayette County 4-H Camp; Fayette County Service Extension Office; 1140 Harry Sykes Way; Lexington KY With the completed registration packet, please make sure to include - the correct payment amount, parent/guardian signature, camper s signature, and a front & back copy of the camper s health insurance or medical card. INCOMPLETE REGISTRATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED. Your child will NOT be considered registered for camp until all completed registration paperwork and the fee are received by the Fayette County Extension Office. Deadline: Orientation: Registrations will be accepted until camp reaches capacity or Friday, May 17, 2019, whichever comes first. Completed camper registrations received after capacity is reached or the deadline date will be put on a waiting list. We will be holding a mandatory camper orientation at 6:00 p.m. on Monday, June 3, 2019, at the Fayette County Extension Service Office, 1140 Harry Sykes Way, Lexington.

3 CAMP SCHOLARSHIPS A scholarship is given based on the funds that are available to any child that qualifies. If you wish to apply for a scholarship, please submit both the scholarship application and a completed camp registration form. A non-refundable $25.00 application fee must be submitted with the scholarship application and the camp registration form. Scholarship applications are available upon request from the FCES Office. For Fayette County Residents Only. Deadline for submission of the scholarship application is when camp reaches capacity or May 17, 2019, whichever comes first. NOTE: The Camp Scholarship cannot be combined with any other discounts (this includes but is not limited to the March 1st discounted rate and the UK Employee discount). ATTENTION CURRENT UK EMPLOYEES One relative of a current UK employee will receive 20% off discount on the camp fee. A photo copy of valid UK Employee ID must be submitted with the completed camp registration form and fee. NOTE: The UK employee discount cannot be combined with other discounts (this includes but is not limited to the March 1st discounted rate and the Camp Scholarship) and applies to only one camper per employee. VOLUNTEERS NEEDED Adult and teen volunteers are needed for a successful camp week. We cannot take campers without adult counselors. One child or relative of an adult camp counselor goes for 50% off. Adult counselors will attend camp for free. Any adult (ages 20 and above) or teen (ages 16-19) interested in being a volunteer should contact the 4-H Office by telephone ( ) or (kevin.lindsay@uky.edu) to request an application. PICK-UP INFORMATION On the camp registration form, you will need to complete a section about who can pick-up your child. Please make sure to include the name and telephone number of each person who can pick-up your child if you are unavailable to do so. The return date is Friday, June 21, Time/location will be announced in the camp newsletter which will be sent out prior to the mandatory camper orientation which is being held on Monday, June 3rd. CLASS SIGN-UP Classes at camp are a great opportunity to learn a new skill or try something new! Each camper will take four classes that last an hour each. They take the same four classes on Tuesday, Wednesday, and Thursday. Sign up for classes will be held at camp. Spots in the classes will be divided evenly between Fayette and Franklin counties. So that the parent/guardian can discuss the classes with the camper, a list of class descriptions is on the back of this page. AGES FOR REGISTRATION Camper: 9-13 years old Camp fee: $ (If the completed registration is received in the FCES office in the by 4:30 p.m. on March 1st, the camp fee is $ ) Deadline: Friday, May 17, 2019 or when capacity is reached, whichever comes first. Ages listed below require applications and are due April 5th. Please call FCES for an application ( ). Counselor In Training: years old Camp fee: $ (If the completed application is received in the FCES office by 4:30 p.m. on March 1st, the camp fee is $ ) Application deadline: Friday, April 5, 2019 Junior Counselor: years old Camp fee: $78.00 Application deadline: Friday, April 5, 2019 Adult Counselor: 20 + years old Camp fee: Free Application deadline: Friday, April 5, 2019

4 Class Descriptions Advanced Swimming - Participate in water activities/games; Use diving board Archery - Learn archery safety and basic skills; Use archery equipment at range Basketball - Learn basic skills and participate in games Beginning Swimming - Lear n basic swim techniques; Par ticipate in water activities/ games Bike - Learn bike safety and about the great outdoors during fun trail riding Canoeing - Learn canoeing safety, basic skills, and water games; Use canoes on lake Crafts - Make various crafts during the week Fishing - Learn fishing safety and basic skills; Fish at the lake Foods - Learn basic food preparation skills and create your own snack foods Gaga Ball - Learn basic skills and participate in games (The game is played within a ring with short panels, and uses a playground ball that is bounced so that players attempt to tag another player in the lower leg with the ball in order to get them out) High Ropes - Learn rock climb wall safety and skills for climbing; Learn zipline safety; Climb 40 foot mock rock wall and zipline down on the other side Leadership - This is open to older youth that want to learn more about leadership, in preparation to being a camp counselor in the future (Counselors in Training must sign up for this class) Low Ropes - Participate in low rope elements not far from the ground, while working as a team to complete challenges (examples: rope bridge crossing, bridge balance, rope spider web activity, and many more) Nature - Learn about nature as you take hikes on the trails around camp Outdoor Living Skills - Learn how to build and cook over campfires; How to build shelters; Get an intro to wilderness first aid Photography - Learn basic photography skills and techniques; Take photos during camp week Recreation - Learn and participate in various games and camp dances Riflery - Learn rifle safety and basic skills; Use equipment at range Soccer - Learn basic skills and participate in soccer games Volleyball - Learn basic skills and participate in games

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 OUTPOST This year an unique camping experience is being offered this summer. Staying at the Outpost offers a more traditional camping experience where campers will spend their week in an open-air shelter rather than a cabin and enjoy a more rustic experience including making campfires at night. If you are interested in staying at Outpost, please check the box below. Space is limited and will be filled on a first-come, first-served basis. Camper would like to participate in Outpost. Campers staying at the Outpost will still participate in all camp activities including classes and will be chaperoned by adult and junior counselors according to camp polices. CABIN MATE What makes 4-H Camp the best is that you get to enjoy it with your friends! In the space below, please print the names of two other campers that you would like to bunk with in the same cabin. This is a request only. We will do our best to honor, but it is not a guarantee. CHECK LIST: Please make sure all items listed below have been addressed on the registration form Completed Camper Registration From Shirt Size Checked Emergency Contact Information is Listed Copy of Front and Back of Camper s Health Insurance Card is included with Registration Form Medical/Behavioral/Special Accommodations Listed on Registration Form Pick-up Release Information Provided (Name, relationship, telephone number) Participant/Camper and Parent/Guardian have signed the Registration Form Camp Fee of $ (check or money order), made payable to Fayette Co. 4-H Camp ($ if received in FCES office by 4:30 p.m. on March 1st.) Requesting Outpost or a Cabin Mate? Please see above.