Date: January To: Prospective 4-H Camp Junior Counselor (JC) From: County Extension Agents for 4-H Youth Development H Summer Camp

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1 : January 2019 To: Prospective 4-H Camp Junior Counselor (JC) From: Kevin Lindsay Madalyn Wells County Extension Agents for 4-H Youth Development Reply to: Cooperative Extension Service Fayette County 1140 Harry Sykes Way Lexington, KY (859) Fax: (859) Fayette.ca.uky.edu RE: H Summer Camp Greetings! This application is for teens wishing to be a Junior Counselor (JC) for Fayette County 4-H camp. Age for JC s are youth age 16 to 19. The 2019 camp week will be with Franklin County 4-H. Location: J.M. Feltner 4-H Camp; London, KY : Monday, June 17 - Friday, June 21, 2019 To be considered for this leadership position, your application must be received by April 5, Due to the rising cost of camp, ALL JUNIOR COUNSELORS ARE REQUIRED TO PAY $78.00 FOR CAMP. Any applications received after the April 5th deadline will be addressed on a case-by-case basis pending the need for additional JC s. You will not be considered registered for camp until all application paperwork and the fee have been received. All JC applicants will be interviewed this year, so it is VERY IMPORTANT to have your completed application packet in by the DEADLINE of April 5, The attached application contains the following items: applicant information page, application checklist, counselor statement of understanding, position description, and recommendation form. You are also required to submit a current color photo of yourself with your application. Incomplete applications will be returned so that they can be corrected by the applicant. If accepted as a JC, you will be required to attend one of the face-to-face trainings listed below and the camper orientation. YOU MUST ATTEND ONE OF THE FACE-TO-FACE TRAININGS AND CAMPER ORIENTATION TO GO TO CAMP!! Training: Saturday, May 18th 9 am - 4 pm Fayette County Extension Office OR Thursday, May 23rd 6-9 pm Franklin County Extension Office 101 Lakeview Court, Frankfort KY AND Orientation: Monday, June 3rd 6-9 pm Fayette County Extension Office To be considered for a Junior Counselor interview, you will need to have the following returned by April 5th. - Counselor Application - Applicant Information Page - Signed Position Description - Recommendation Form - Signed Counselor Statement of Understanding Do not include relatives or Fayette County 4-H Staff members. - $78.00 payment (check or money order) Thank you in advance for applying to become a 4-H camp JC for If you have any questions, please contact us by (kevin.lindsay@uky.edu or madalyn.wells@uky.edu) or by telephone at (859)

2 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?

3 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):

4 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: : Parent/Guardian Signature: :

5 Fayette County 4-H Camp Teen Counselor Application Checklist Please return this checklist with your application. (Eligible: Youth, ages years old) 2019 Summer 4-H Camp Participant Registration Form & Copy of Insurance Card Current color photo of applicant - (please attach below) Junior Counselor Statement of Understanding Junior Counselor Information Page Camp Junior Counselor Position Description Camp Counselor Recommendation Form Do not include relatives or Fayette County 4-H Staff members. Camp Fee of $78.00 (Check or Money Order payable to Fayette Co 4-H Camp) Application Received: FOR OFFICE USE ONLY: Interview & Time: Attach Color Photo Here Completed Volunteer Application Packet: YES NO Verified By: Completed Summer H Camp Application : YES NO Verified By: Online Camp Training Successfully Completed: YES NO Verified By: Confirmed Attendance of face to face training: YES NO Verified By:

6 Fayette County 4-H Camp Junior Counselor Statement of Understanding By signing below, I am stating that I understand the following items and/or requirements: 1. If I am chosen as a counselor, the attendance of many campers is solely dependent upon my attendance. In the event that my availability changes, I will immediately notify the 4-H Agent responsible for my week of camp. 2. I am required to attend an interview where I will be asked questions regarding my experience in camping and programming with youth. Counselors that have previously attended 4-H Summer Camp will also be asked to provide feedback on their experiences. 3. I am required to attend one of the face-to-face trainings listed below and camper orientation. I understand I will not be permitted to attend camp without attending one these face to face trainings and camper orientation. Training: Saturday, May 18th 9 am - 4 pm Fayette County Extension Office OR Thursday, May 23rd 6-9 pm Franklin County Extension Office 101 Lakeview Court, Frankfort KY AND Camper Orientation: Monday, June 3rd 6-9 pm Fayette County Extension Office Junior Counselor Applicant Signature Applicant Parent/Guardian Signature

7 Fayette County Junior Counselor Information Page Applicant Name: Years at camp: Years in 4-H: address: Cell Phone: Can you send & receive text messages? Are you will to assist with classes? Yes No If yes, please indicate areas of interest below: How do you feel you could help with these classes? (Be specific) T-Shirt Size: (adult sizes) Small Medium Large XL 2XL List any 4-H activities (including camp) that you have been involved in over the past year: What abilities and/or personal strengths do you have that you can use as a Camp Counselor? Teen Volunteer Agreement Form By signing this document, I understand that I will be expected to complete leader trainings (BOTH online and face to face) prior to the stated deadlines. I also agree to abide by the University of Kentucky s 4-H Camper/Counselor Expectations (enclosed in this application packet) and I understand I could be dismissed from camp and not allowed to return in the future for inappropriate behavior. Signature Parent/Guardian Signature

8 HR-6 4-H CAMP POSITION Camp Junior Counselor VOLUNTEER POSITION DESCRIPTION Kentucky 4-H Youth Development Program; Fayette County The University of Kentucky Cooperative Extension Service The University of Kentucky POSITION TITLE: 4-H Camp Junior Counselor TIME REQUIRED: Training prior to camp Five (5) days/ (4) evenings LOCATION: 4-H Camp Ground located at: J.M. Feltner 4-H Camp Face-to-Face Training: Fayette County Cooperative Extension Service Office or Franklin County Extension Service Office Camper Orientation at: Fayette County Cooperative Extension Service Office GENERAL PURPOSE: + Supervision of youth, ages 9-15, 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 camp activities + Encourage all campers to participate in camp activities + Counsel homesick campers + Follow all guidelines and policies of the University of Kentucky and 4-H programs + Be responsible for the health, safety and happiness of each camper in their cabin + Actively participate in implementing the camp s programs + Assist in keeping camp ground clean + Assist campers in making choices in activities + Encourage campers to try new activities + Stay with cabin/tribe at all times, unless permission is granted by camp director + Assist adult counselors, permanent staff and agents, upon request, with special activities such as quiet time, flag raising/ lowering, etc. + Assist with bus loading and unloading + Assist class instructors where needed in teaching or in managing campers behavior + Project a positive and enthusiastic attitude about camp which campers may model + Report any problems to your adult counselor, Dean of Men/Women or your county 4-H Agent

9 QUALIFICATIONS: + Must be 16 years - 19 years old at time of camp + A sincere interest in youth development + Ability to work and communicate effectively + Willingness to follow rules + Ability to get along with others + Positive attitude + Ability to follow instructions at camp, especially during an emergency situation + Completed camp and health forms; including the required Tetanus vaccination BENEFITS: + Developing positive relationships with campers, adult counselors and CES staff + Seeing youth develop and gain skills + Appropriate training, teamwork and support + Opportunity to share in an exciting week of activities with youth + Chance to share ideas with other adult and teen leaders SALARY: Unsalaried; Volunteer. Fees for Junior Counselors: $78.00 Transportation provided MENTOR/SUPERVISING PROFESSIONALS: County Extension Agents for 4-H Youth Development Name: Kevin Lindsay Address: 1140 Harry Sykes Way City, State, Zip: Lexington, KY Phone: Fax: Kevin.Lindsay@uky.edu Signature Parent/Guardian Signature 4-H Agent Signature

10 Fayette County 4-H Camp Junior Counselor Recommendation Form Do not include relatives or Fayette County 4-H Staff members. Name of Applicant: I am interested in being a counselor at 4-H Camp this summer. The County Extension Agents for 4-H Youth Development would like your input about my qualifications to fulfill the responsibilities of a camp counselor. Please comment on the following topics and return this form to the address listed below by April 5th. Thank you. Kevin Lindsay Fayette County Cooperative Extension 1140 Harry Sykes Way Lexington, KY How would you rate the applicants? Above Average Average Below Average Emotional maturity/judgment Leadership Abilities Flexibility Communication skills Enthusiasm and energy Self confidence Respect for authority Completion of tasks Working with youth Responsibility Have you seen this applicant in a leadership position? If yes, please explain in what capacity. Please describe this applicant s ability to work with others on a team. Why would you recommend this applicant to be a 4-H Camp Junior Counselor? (be specific) Additional comments: _ Printed Name Signature Relationship to applicant: Please return to the Fayette County Cooperative Extension Office by April 5th, 2019.