Dear Parents and Campers!

Dear Parents and Campers! Welcome to the 2018 4-H/Pre- Teen Xtreme Camp! This year s camp will take place at Camp Round Meadow Catoction Mountain in Thurmont, Maryland and will be held from August 6-10, 2018. You already know that camp presents a tremendous opportunity for your child to broaden horizons, make new and lasting friends, and discover new strengths. After all, you wouldn t be considering camp if you didn t think it would add substantially to your child s growth and development. Although camp can help your child learn leadership, teambuilding, make healthy lifestyle, eating and physically choices, and improve a skill in just about any physical endeavor, the true payoff of camp will be apparent when your child comes home more self-reliant, selfsufficient, and self-confident. What a gift to give to your child! We know that you are sending your most cherished loved ones to camp with us and we hope that you don t think it s strange of us to ask you to take some time to write down a few things that you would want us to know about your child. Oh sure, there are those official camp forms where you tell us what your son or daughter is allergic to, physical description and if they re immunization are current, but we also want to know who they are as a person and their interest. We want the campers stay to be a life time memory as it was for many of the staff that went to camp as a child. To help the campers understand the diversity in their community, getting along with other campers, improve their interpersonal and leadership skills, and youth/adult partnerships we are planning the camp s activities around a new 4-H curriculum called: Up For the Challenge: Lifetime Fitness and Healthy Decisions. We will be using our Teen Leaders as Teachers. The campers will be also participating in the usual camp activities of swimming, hiking, arts & crafts, good fun and of course the Thursday night dance. We will keep the campers moving all weekend to creative movement to music. We are an accredited camp through the American Camping Association (ACA). This is verification from the ACA that our camp has complied with up to 300 industry-established health and safety standards, which are recognized by courts of law and government regulators as the standards of the camp industry. In 2001 our camp won the Eleanor P. Eells Award from the ACA for program excellence. We were nominated for this award again for our 2002 camp and placed in the top five in the country. The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 1

Attached is a final list of items campers need to bring with them to camp. Below is emergency contact information for the camp ground: Catoctin Mountain Park 6602 Foxville Road Thurmont, MD 21788-2598 Should you have any further questions or concerns, please feel free to contact Pam Mack 301-868-9636. Thank you and we look forward to seeing you at camp! Lenora Harper Lenora Harper Camp Director The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 2

4-H CAMP PACKING INFORMATION Welcome to the 4-H Xtreme Teen Camping Trip! Your participation in all scheduled programs, contributions to sessions, and friendly attitude will make this an exceptional four and a half day experience. You will meet new people, explore new ideas, share your interests, and speak out on issues that matter to you. What is Camp about? We are an accredited camp through the American Camping Association (ACA). This is verification from the ACA that our camp has complied with up to 300 industry-established health and safety standards, which are recognized by courts of law and government regulators as the standards of the camp industry. In 2001 our camp won the Eleanor P. Eells Award for the ACA for Program Excellence. We were nominated for this award again for our 2002 camp and placed in the top five in the country. Who, when and Where? The camp will take place at the Camp Round Meadow-Catoctin Mountain Park, 14840 Manahan Rd, Sabillasville, Maryland, from August 6-10, 2018. Youth between the ages of 9-13 are allowed to participate. Getting There: We ll be using a commercial bus. From Washington DC take the 495 north to I270 north 27 miles to Frederick, MD. Take Route 15 17 miles north to Thurmont, MD. Take Route 77 West, the exit sign is marked Catoctin Mountain Park. Travel approximately 6 miles west on 77 (you will pass Park Central Road and the park Visitor Center) and turn right onto Foxville-Deerfield Road. As the road forks, turn right onto Manahan Road. Continue approximately 3/4 mile and turn left into Camp Round Meadow. Park in the large gravel parking lot. When You Arrive at E-Church Parents/Guardian must check you in at the registration area before boarding the bus. All Medications must be turned in at the registration area. It is important to arrive on time because we will be leaving E-Church at 8:00 a.m. SHARP! The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 3

What to Bring A checklist for camp is attached to this letter. Leave items of value at home. The program cannot be responsible for items lost during camp. Dress for camp is fun wear you will need to bring bed linens, towels, and personal care items. Please be sure that everything you bring to camp is clearly marked with your name. Cabin Living Camp gives you a chance to experience all aspects of outdoor living. Camp participants will be housed with eight teens and two counselors. This is a great chance to get to know teens from other areas. Cabin changes cannot be granted during camp. While you are at camp remember that you represent yourself, your community and family. Treat all property with respect. Males and female are housed separately and teens are not permitted to visit the rooms of opposite sex participants. We will have cabin meetings at night to answer any questions about the next day and to help you solve any problems you may have encountered. Transportation A bus will be picking up and dropping off camp participants from Kentland Community Center. Please have someone bring and pick up from this location. You will not be allowed to leave your personal vehicle on the premises. Special Needs If you have any needs which require modifications in housing, meals, or program, please contact Lenora Harper by Friday July 20, 2018 with your requests so that appropriate accommodations can be made. What Not To Bring to Camp Weapons (knives, guns, etc.) No food No Sandals No! electronics of any kind: cell phone, ipod/ipad, tablet, MP3/dvd/cd players, gaming systems Packing Checklist: Medication Bring comfortable outfits Sleepwear One piece swimwear (ONLY) 1- Towel for pool Shower shoes or flip flops Comfortable walking shoes Light jacket or sweater Sunscreen Sleeping bag or bed linen and pillow Personal items Disposable Camera The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 4

Sample Day at Camp 9 am Breakfast 5pm 6pm Dinner 10am 12pm Safe Day Activities 6pm 8pm Water Games 12pm 1pm Lunch 8pm 10pm Camp Fire/Snack 1pm 2pm Safe Day Activities 10pm 11:30pm Talent Show 2pm 4pm Swimming/Snack 11:30pm 12 am Rap Sessions 4pm 5pm Quiet Games/Arts n Crafts 12am Lights Out Special Events tentatively scheduled for this year s camp trip: Field Day International Day Talent Show REQUIREMENTS Must be a teen between the ages of 9-13 Must be an ACTIVE member in the 4-H Club or their community Must have a valid Maryland-National Capital Park and Planning Commission Center ID Card Questions-If you need additional information about camp please contact Lenora Harper 301-386- 2278. The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 5

Drop-off and Pick-up Location: E-Church 1907 Columbia Ave Landover, Maryland 20785 (301) 386-2278 Drop-off: Monday, August 6, 2018 @ 7:30 am Pickup: Friday, August 10, 2018 @ 2:30 pm The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 6

4-H Teen Camp Checklist: Complete ALL forms below, return with checklist and payment. Camper s Name: 1. Registration Form and payment 2. Maryland 4-H Behavioral Expectations & Disciplinary Policy & Procedures- (3 pages) 3. Maryland Parental Release and Informed Consent Form- (2 pages) 4. Photograph Release Form 5. Member Enrollment 6. Maryland 4-H camps Health Form (6 pages) FYI-Please keep Welcome letter, 4-H Camp packing information, and Times for Drop-off & Pick up! The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 7

Registration Packet Mail Registration Forms and Payment to: University of Maryland Extension Attn: Pam Mack 6707 Groveton Drive Clinton, MD 20735 FEES and CHARGES Total Camp Fee per camper (Ages 9-13) $100.00. Campers must show proof of residents and school attendance i.e. report card (submitted along with camp application) Payment Deadline: Friday, July 20, 2018. All paperwork must be completed and accompany the youth prior to camp. Any youth that does not have all required paperwork completed WILL NOT be allowed to go to camp NO EXCEPTION! DETAILS: Only Cash and Money Orders will be accepted! NO CHECKS WILL BE ACCEPTED Please make money order payable to: Prince George s County Extension Advisory Council - PGCEAC CANCELLATION AND REFUNDS: A two (2) week cancellation notice is required! Cancellation and refund request on both partial and fully paid registrations are subject to a $25.00 cancellation fee per person. NO EXCEPTIONS! For more information, please call Pam Mack at 301.868.9636 REGISTRATION FORM Camper s Name: Age: DOB: Parents/Guardian s Full Name: Street Address: City: State: Zip Code: Work Phone: Home Phone: Circle and list Information Dietary / Disability / Health Concern I have read all information started I this brochure from camp management and I agree to all the terms stated above. Parents/Guardian Signature Date The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 8

Maryland 4-H Behavioral Expectations A goal of the Maryland 4-H program is to provide opportunities for children and youth to build character. Maryland 4-H supports the CHARACTER COUNTS!SM six pillars of character: TRUSTWORTHINESS, RESPECT, RESPONSIBILITY, FAIRNESS, CARING AND CITIZENSHIP. In order to ensure that Maryland 4-H programs provide positive environments for all individuals to learn and grow, 4-H participants agree to abide by these expectations of behavior: (CHARACTER COUNTS! Is a service mark of the CHARACTER COUNTS! Coalition, a project of the Josephson Institute of Ethics.) I will be trustworthy. I will be worthy of trust, honor and confidence. I will be a model of integrity by doing the right thing even when the cost I high. I will be honest in all my activities. I will keep my commitments by attending all sessions of the planned event. If I am not feeling well or have a schedule conflict, I will inform my chaperon or a person in charge. I will be in the assigned area (e.g., club meeting room, building, and dorm) at all times. Maryland 4-H does not permit dishonesty by lying, cheating, deception or omission. I will be respectful. I will show respect, courtesy, and consideration to everyone, including myself, other program participants and those in authority. I will act and speak respectfully. I will treat program areas, lodging areas, and transportation vehicles with respect. I will not use vulgar or abusive language or cause physical harm. I will appreciate diversity in skill, gender, ethnicity and ability. Maryland 4-H does not tolerate statements or acts of discrimination or prejudice. I will be responsible. I will be responsible, accountable and self-disciplined in the pursuit of excellence. I will live up to high expectations so I can be proud of my work and conduct. I will be on time to all program events. I will be accountable by accepting responsibility for my choices and actions. I will abide by the established program curfew. I will be responsible for any damage, theft or misconduct in which I participate. I will be fair. I will be just, fair and open. I will participate in events fairly by following the rules, not taking advantage of others and not asking for special exceptions. I will be caring. I will be caring in my relationships with others. I will be kind and show compassion for others. I will treat others the way I want to be treated. I will show appreciation for the efforts of others. I will help members in my group to have a good experience by striving to include all participants. I will be a good citizen. I will be a contributing and law-abiding citizen. I will be respectful to the environment and contribute to the greater good. I will not use any illegal substances such as tobacco, alcohol and drugs. The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 9

Maryland 4-H Disciplinary Policy and Procedures I. Maryland 4-H expects youth participating in programs to behave in an acceptable manner and in accordance with the Maryland 4-H Behavioral Expectations outlined on the reverse side of this document. 4-H participants who engage in unacceptable conduct, including the following behaviors, are subject to discipline. Possession, use, or distribution of alcohol and/or illegal drugs. Possession or use of weapons or dangerous materials. Possession or use of tobacco products. Misuse of prescription or nonprescription drugs. Sexual activity. Lying, cheating, and misrepresenting project work or other unethical practices. Unauthorized absence from program site. Physical, verbal, emotional, or mental abuse of, or threats toward another person. Theft, destruction, or abuse of property. II. III. A participant in a 4-H program who engages in conduct (including the above behaviors) that, in the discretion of the extension faculty, staff or MCE volunteer in charge, may jeopardize the health or safety of the participant or others, or the integrity of 4-H, will be dismissed immediately from the program (meeting, activity, event, trip, camp, etc.). The participant s parent or guardian will be responsible for providing transportation home for a child if dismissed. Following a program, a participant and his/her parent or guardian will be notified in writing of the nature of any unacceptable conduct for which sanctions (up to and including suspension from one or more 4-H programs or dismissal from (4-H) are being considered. In such cases: The extension faculty or staff member with overall responsibility for the program will set up a meeting to hear the 4-H member. The 4-H member s parent or guardian will be permitted to be present at such time. At the discretion of MCE or at the request of the 4-H participant, a committee may be appointed by MCE to review the matter. Following the meeting, the 4-H participant and his or her parent/guardian will be notified in writing of the outcome of the meeting and any sanction(s) to be imposed. Sanctions may be appealed in writing within seven (7) days after receiving notice of the decision, to the County Extension Director (CED). In the event that the extension faculty in charge also serves as the CED, the appeal will be made to the Regional Extension Director (RED). The 4-H participant and his/her parent or guardian will be notified in writing of the decision of the CED (or RED). The decision of the CED (or RED) may be appealed in writing to the State 4-H Leader within seven (7) days after receiving notice of the decision. The decision of the State 4-H Leader will be final. I HAVE READ THE MARYLAND 4-H BEHAVIORAL EXPECTATIONS AND THE MARYLAND 4-H DISCIPLINARY POLICY AND PROCEDURES. I AM AWARE THAT MY ACTIONS AND DECISIONS AFFECT ME AND OTHERS AND MAY RESULT IN LOSS OF PRIVILEGES DURING 4-H PROGRAMS, AND FOR FUTURE PROGRAMS. I WILL ACCEPT THE APPROPRIATE AND LOGICAL CONSEQUENCES OF MY ACTIONS, AS DETERMINED BY MARYLAND 4-H. Member Signature Date AS THE PARENT/GUARDIAN OF, I HAVE READ THE MARYLAND 4-H BEHAVIORAL EXPECTATIONS AND THE MARYLAND 4-H DISCIPLINARY POLICY AND PROCEDURES AND WILL SUPPORT THE INDIVIDUAL IN CHARGE IN MAINTAINING APPROPRIATE BEHAVIOR. I AGREE TO ACCEPT THE APPROPRIATE AND LOGICAL CONSEQUESNCES OF MY CHILD S ACTIONS AS DETERMINED BY MARYLAND 4-H. Parent/Guardian Signature Date It is the policy of the University of Maryland, Agricultural Experiment Station and Maryland Cooperative Extension, that no person shall be subjected to discrimination on the grounds of race, color, gender, religion, national origin, sexual orientation, age, marital or parental status or disability. 10

UNIVERSITY OF MARYLAND UNIVERSITY OF MARYLAND EXTENSION PARENTAL RELEASE AND INFORMED CONSENT FORM PROGRAM: 4-H Xtreme Teen Camp DATE(S): August 6-10, 2018 My minor child, as listed below, has my permission to fully participate as a representative of the University of Maryland Extension (UME) Maryland 4- H Youth Development Program in all activities associated with the above named program. In connection with and consideration of my child s participation in the Program, I, on behalf of my child and myself, my heirs, personal representative(s) and assigns, hereby represent and agree as follows: 1. I am aware that any program related activity can be dangerous, and I fully recognize and understand that there are risks and hazards, both minor and serious, associated with participation in the Program and related activities, including, but not limited to: cuts, scrapes, bruises, broken bones, muscle strains, pulls or tears, head, neck, back, eye and other bodily injuries, heat prostration, brain damage, blindness, deafness, drowning, heart attacks, paralysis and, even, death. The following is a description and examples of specific, significant, non-obvious dangers and risks associated with this activity. There is potential for accidents and/or injuries arising from: (Add the activities here see sample for suggestions) a. Transportation to and from camp (Camp Round Meadow Thurmont, MD) b. General camping activities c. Hiking d. Swimming 2. I understand that my child is not in any way required to participate in the Program, but I want them to participate, despite the possible dangers and despite this Release. 3. I represent and warrant that my child has no physical, health related or other problems which would preclude or restrict their participation in the Program or otherwise render their participation dangerous or harmful to them or others. I further represent and warrant that my child has adequate medical, health and/or other insurance for participation. 4. Knowing the dangers, hazards and risks associated with the Program, and with sufficient knowledge of my child s physical condition(s) and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage, illness and/or injury to person or property which my child may, in any way, sustain in connection with participation in the Program and related activities. 5. I agree that my child must abide by all rules and regulations applicable to participation in the Program. Should my child require emergency medical treatment or first aid as a result illness or injury associated with the Program or related activities, I consent to such first aid and/or treatment. 6. To the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and to indemnify and hold harmless, the State of Maryland, the University of Maryland, University of Maryland Extension and their governing boards, officers, agents, employees and volunteers from and against any and all liabilities, claims, demands and causes of action of any kind on account of any loss, damage, illness or injury to person or property in any way arising out of or relating to my child s participation in the Program and/or related activities, whether due to the negligence, mistake or other action or inaction of UME or any other person or entity. 7. I do hereby consent and agree that the Maryland 4-H Youth Development Program has the right to take photographs or record video/audio tapes of my child and to use these for educational and/or promotional materials. I further consent that my child's name may be revealed therein or by descriptive text or community. I hereby release to the Maryland 4-H Youth Development Program all rights to exhibit this work publicly or privately, including posting it on the Maryland 4-H Website. I waive any rights, claims or interests I or my child may have to control the use of my child's identity or likeness in the photographs, video or audio, and agree that any uses described herein may be made without compensation or additional consideration of me or my child. I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ AND FULLY UNDERSTAND THIS RELEASE AND INFORMED CONSENT FORM, AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE. Signature of Parent/Guardian Having Care and Custody of Participating Child Date Name of Parent/Guardian: Emergency Telephone: ( ) Participating Child s Name: Signature: Age: University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or parental status, or national origin. Rev. - July 2000 (D. Andrews) Updated for Extension Name and Logo Change AMT 3/2010 The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 11

University of Maryland Extension Prince George s County 6707 Groveton Drive Clinton, MD 20735 301-868-9636 (phone) 301-599-6714 (fax) PHOTOGRAPH RELEASE FORM Prince George s County 4-H Camping Program During 4-H Camp at Camp Round Meadow; camp staff, directors, and counselors take photographs of the children involved in various activities throughout the week. These photos may be used on the Prince George s County 4-H website, camp website, in the 4-H newsletters, and brochures. Initial one of the following: I grant permission I do not grant permission for my child s photographs from the 2018 4-H Camp to be used in Prince George s County 4-H publications. I understand granting permission will allow the general public to view these photos. I do hereby release, discharge and hold harmless and indemnify the University of Maryland Extension, University of Maryland System, and State of Maryland, and all regents, officers, employees, agents, successors and assigns thereof, from any and all claims and demands of whatever nature, actions, causes of action appeals, obligations, liabilities, promises, suits, rights, charges, damages, punitive damages, cost, loss of service, loss of employment opportunity, emotional suffering, cost of litigation, humiliation, embarrassment, mutual anguish, injury of reputation, personal injury, and any and all other legal, equitable or administrative relief of any kind, known or unknown, suspected or unsuspected, having already resulted or to result in the future, as a result of or relating to my participation in the above program and/or activity. I, the undersigned, acknowledge that I sign this Release knowing and intelligently and with full and complete knowledge of the purpose of said program and without any form of duress and/or intimidation whatsoever on the part of the University of Maryland Extension, or University of Maryland System. Parent/Guardian Signature: Date: Child s Name: The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 12

4-H Year: 2018 Youth Enrollment Form 4-HOnline - Prince George's County Family Name Family Email Send Correspondence No Yes Correspondence Pref. Postal Mail Email First, Middle, & Last Name Preferred Name Mailing Address 2 State Mailing Address City Zip Code Birth Date Gender Male Female Primary Phone Work Phone Fax Parent / Guardian 1 First Name Cell Phone Cell Phone Work Extension Years in 4-H Last Name Work Phone Parent / Guardian 2 First Name Cell Phone Last Name Work Phone Second Household Send Correspondence No Yes Correspondence Pref. Postal Mail Email Family Name First Name Primary Phone Address 2 State Email Emergency Contact Name Address City Zip Code Phone Cell Phone Relationship Enrollment Ethnicity Are you of Hispanic ethnicity? No Yes (please indicate both an ethnicity and race) Race White Black American Indian or Alaskan Native Native Hawaiian or Pacific Islander Asian Prefer Not to State Residence Farm (rural area where agricultural products are sold) Suburb of city more than 50,000 The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 13

Town under 10,000 and rural non-farm Central city more than 50,000 Town / City 10,000-50,000 and its suburbs Military No one in my family is serving in the military I have a sibling serving in the military I have a parent serving in the military Branch Air Force Army Coast Guard DOD Civilian Marines Navy Active Duty National Guard Reserves The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 14

Youth Enrollment Form 4-HOnline - Prince George's County 4-H Year: 2018 Grade School Type Clubs Primary Club: Public School Private School Special Education Vocational Education 4-H Teen Xtreme Camp School Name Homeschool / Alternative Magnet / Specialized School Charter School Secondary Club: Refer to the 4hOnline Enrollment & Project Guide to select projects List selected projects below. 4-H Camping Activities Projects Signature Parent / Guardian Signature Date Date The University of Maryland, College of Agriculture and Natural Resources programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national origin, marital status, genetic information, or political affiliation, or gender identity and expression. The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.) 15

MARYLAND 4-H CAMPS Sunscreen Authorization Form Dear Parents: The Maryland Department of Health and Mental Hygiene has adopted a policy regarding the use of sunscreen at youth camps. In order to operate a camp in the state of Maryland, we must abide by the policy as outlined below. Please read the following regarding use and application of sunscreen at Maryland 4-H Camps. The authorization statement must be completed and submitted along with sunscreen labeled for your camper (one form and bottle per camper) on the first day of camp, at the start of each subsequent week, if the brand of sunscreen changes, or if a new bottle is supplied at any time. Please address questions about this policy to your Camp Coordinator. MARYLAND 4-H CAMPS SUNSCREEN POLICY 1. Each Camper s parent/guardian must provide written permission for use and application of sunscreen on their child. 2. Sunscreen containers must be clearly labeled with the Camper s name and must be provided to Camp Staff at camp check-in. This signed authorization form must submitted along with the sunscreen. 3. Campers should, in most instances, apply the sunscreen on their own. If assistance is needed it will be provided by Camp Staff ONLY if specifically authorized (see below). 4. For Day Camps, Campers need to have sunscreen applied to them by the parent/guardian BEFORE arriving at camp, not when dropping off. MARYLAND 4-H CAMPS SUNSCREEN AUTHORIZATION (Complete and sign appropriate block below) Camper s Name: Camper s Age: Brand of Sunscreen: SPF: Expiration Date: I give permission for members of the Maryland 4-H Camp Staff to assist in applying sunscreen to my child. I understand that this may require the staff member to touch my child s face, shoulders, back, arms, and lower legs. Sunscreen will be applied in the presence of other staff members. I understand that staff will not apply sunscreen to my child s front torso or upper legs, but will assist and/or direct the child to do so. In the event my child does not bring sunscreen to camp and conditions warrant its use, by my signature below I authorize members of the Maryland 4-H Camp Staff to use camp supplies of sunscreen, and to apply this sunscreen to my child s body as described above. Parent/Guardian s Printed Name Parent/Guardian s Signature OR Date I DO NOT give permission for Maryland 4-H Camp Staff Members to assist in applying sunscreen to my child. Parent/Guardian s Printed Name Parent/Guardian s Signature Date University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression. 4/2015

Cell Phone Statement At 4-H Pre-Teens Camp, we have always had a no cell phone policy. Due to potential liabilities, enforcement of this policy is crucial to our continued camp success. Aside from the fact that cell phones are expensive and can get lost or stolen and that the physical camp environment is not kind to such items, there is a fundamental problem with campers having cell phones at camp, and that is trust. When children come to camp they and you-are making a leap of faith, transferring their primary care from you as their parents to us and their counselors. This is one of the growth-producing, yet challenging aspects of camp. As children learn to trust other caring adults, they grow and learn, little by little, to solve some of their own challenges. We believe this emerging independence is one of the greatest benefits of camp. It is one important way your children learn to become resilient. Contacting you by phone essentially means they have not made this transition. It prevents us from getting to problems that may arise and addressing them quickly. Sending a cell phone to camp is like saying to your child that you as the parent haven t truly come to peace with the notion of them being in our care. You can help by talking with your child before they leave for camp and telling them that there is always someone they can reach out to; whether it is a counselor, a trusted activity leader, the head counselor or even the director. We are here to help, but if you don t trust us, they certainly won t. It is important to understand why cell phones are not only disruptive but can lead to other situations. Cell phones that are cameras can be used to take pictures in cabins that might accidentally catch another camper indisposed. That picture can then be sent out via picture mail, posted to Facebook, etc. That is not a situation that the camper, their parents or us as a camp staff want to happen. This is just one of the possible situations that can occur if you allow your child to bring a cell phone to camp. Any cell phone that is brought to camp and will be collected and held until the end of the week and WILL NOT BE RETURNED until the buses are being boarded. Disciplinary action may be taken depending on the circumstances. I,, have read the above information and agree not to bring a cell phone to camp. I understand that if I am seen with a cell phone during any part of my time at camp, it will be collected and held until the end of the week. This could affect whether or not I will be asked to participate in camp the following year as a leader. Signature of Camper Signature of Parent/Guardian ***your child will not be permitted to board the bus unless this form is signed and on file with camp staff*** The University of Maryland, College of Agriculture and Natural Resources programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national origin, marital status, genetic information, political affiliation, or gender identity and expression.

MARYLAND 4-H CAMPS HEALTH FORM Camper s Name: Last First MI Nickname Current Photo Of Camper Male Female Home Address: Age at Camp Arrival: Birthdate: MM/DD/YYYY Dates will attend Camp: to MM/DD/YYYY MM/DD/YYYY Street Address City State ZIP County School Attended: County: Private Public Other School Address: Street Address City State ZIP PARENT/GUARDIAN To be Notified in case of Injury or Illness: Name: Relationship: Preferred #1 E-mail: Phones: #2 Indicate mobile (M), home (H), work (W) Home Address: if different from camper Street Address City State ZIP SECOND PARENT/GUARDIAN Or other Emergency Contact: Name: Relationship: Preferred #1 Phones: #2 E-mail: Indicate mobile (M), home (H), work (W) ADDITIONAL CONTACT in event parent(s)/guardian(s) cannot be reached: Name: Relationship: Preferred #1 Phones: #2 E-mail: Indicate mobile (M), home (H), work (W) HEALTH CARE PROVIDER CONTACTS Name: Phone: Primary Care Physician: Dentist: Orthodontist: Other Provider (Specify): HEALTH INSURANCE: Is camper covered by health/medical insurance? Yes No Insurance Company: Phone Number: Policyholder s Name: Policy Number: Camper has mild/moderate allergies Camper has severe allergies that require immediate medical attention: Camper carries an Epi-pen, inhaler, or other emergency device: Attach photocopy of insurance card; be sure to copy both sides of card so information is readable CAMPER HEALTH SUMMARY (Camp Use - See additional pages for detailed health history) Camper takes daily medication Camper has dietary needs or restrictions Camper has physical limitations or disability Camper has personal issues/needs: University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression. 4/2016

CAMPER HEALTH HISTORY Page 2 Camper s Name: Age: Birthdate: IMMUNIZATION CERTIFICATION: State in which camper resides/attends school: Date of last Tetanus Is camper exempt from any immunizations? Yes No immunization: List: I certify my child has received and is up-to-date on all immunizations required for school attendance in the state where s/he lives/attends. If my child has not received required immunizations, I certify the appropriate exemptions or exceptions have been recorded with my child s school. I understand and accept the risks of my child not being fully immunized per state requirements. Signature of Parent/Guardian: Date: Relationship to Camper: GENERAL HEALTH HISTORY: Check Yes or No for each statement. Explain yes answers in space below. Has/does the camper: 1. Ever been hospitalized? Yes No 12. Had fainting or dizziness Yes No 2. Ever had surgery? Yes No 13. Passed out/had chest pain during exercise? Yes No 3. Have a recurrent/chronic illness? Yes No 14. Had mononucleosis (mono) in the last month? Yes No 4. Had a recent infectious disease? Yes No 15. If female, had problems with period/menstruation? Yes No 5. Had a recent injury? Yes No 16. Have problems with falling asleep or sleepwalking? Yes No 6. Had a recent head injury or concussion? Yes No 17. Ever had back/joint problems? Yes No 7. Had asthma/wheezing/shortness of breath? Yes No 18. Have a history of bedwetting? Yes No 8. Have diabetes? Yes No 19. Have problems with diarrhea or constipation? Yes No 9. Had seizures? Yes No 20. Have any skin problems? Yes No 10. Had headaches? Yes No 21. Traveled outside the country in the past 9 months? Yes No 11. Wear contact lenses, glasses, or protective eyewear? Yes No 22. Have any other condition or issue not listed? Yes No Explain yes answers in the space below, noting the question number. For travel outside the country, list countries visited and dates of travel. ALLERGIES: No known allergies Allergic to: Foods Medicines Environment Other (Circle all that apply & describe below. Attach additional pages if necessary) What is camper allergic to? (Specific) What is the typical reaction seen? What is treatment is needed? DIET/NUTRITION: Eats regular diet Eats regular vegetarian diet Notes about camper s diet/nutrition: Lactose intolerant Glucose intolerant Other (Please explain below) MENTAL, EMOTIONAL, AND SOCIAL HEALTH: Check yes or no for each statement. Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)? YES NO 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? YES NO 3. In the past 12 months, seen a professional to address mental/emotional health concerns? YES NO 4. Had a significant life event that continues to affect the camper s life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, etc) YES NO 5. Is this the camper s first time away from home/family for an overnight event? YES NO Please explain yes answers in the space below, noting the number of the question. Attach additional pages if needed. The camp may contact you for additional information. University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression. 4/2016

CAMPER HEALTH HISTORY Page 3 & AUTHORIZATION Camper s Name: Age: Birthdate: ADDITIONAL INFORMATION: Please provide any additional information about the camper s health or well-being you think may be important for staff to know or that may affect the camper s ability to fully participate in the camp program. Attach additional pages if needed. RESTRICTIONS: I have reviewed the program and activities of the camp and feel the Camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the Camper can participate with the following restrictions or adaptations (please describe): AUTHORIZATION FOR PARTICIPATION, TREATMENT, AND RELEASE OF LIABILITY I certify that this health history is correct and accurately reflects the health status of the camper to whom it pertains. I hereby give permission for medical personnel selected by University of Maryland Extension (UME) to provide routine health care; to order x-rays, and routine tests; to administer medications, injections, anesthesia, surgery, and other treatment; to release records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission for medical personnel selected by UME to secure and administer treatment including hospitalization for the participant named above. I further understand that I will be responsible for medical/hospital bills. By signing this form, I give permission for the participant named above to participate in all program activities except as specified herein. This completed form may be copied for trips out of camp and/or away from the program site. By signing this form, I release and forever discharge, agree not to sue, and to indemnify and hold harmless the State of Maryland, University of Maryland, and University of Maryland Extension and/or their officers, agents, employees, faculty, staff, and volunteers from and against any and all liabilities, costs, expenses, causes of action, claims, and/or demands in any way relating to the foregoing program activities and/or the health, illness, injury, and/or treatment of the participant named above. Signature of Parent/Guardian: Signature of Adult Camp Participant: (over 18 years of age) Date: Date: Relationship to Camper: University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression. 4/2016

CAMPER MEDICATIONS Page 4 Camper s Name: Age: Birthdate: Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. Campers who will take daily medications, vitamins, supplements, etc. while attending this 4-H Camping Program must complete the Medication Administration Authorization Form, which must be signed by BOTH the Camper s Parent/Guardian and the prescribing Physician. Campers who will take daily medications must bring their own supply of prescription or non-prescription medications, and the supply must be provided by an adult to the Camp Staff upon arrival. See the Medication Administration Authorization Form for further details and instructions. Check the applicable statement below: Camper WILL NOT bring/take daily medication(s), vitamins, or supplements while attending camp. Camper WILL bring/take daily medication(s), vitamins, or supplements while attending camp.* *Medication Administration Authorization Form is required CAMP HEALTH CENTER MEDICATIONS & REMEDIES The Camp will stock certain non-prescription medications and remedies in the Camp Health Center that may be used on a one-time or limited asneeded basis to manage minor illness and injury. Dosages of these medications and remedies will be administered according to directions on the label unless the Camper s Parent/Guardian provides written direction provided for alternate dosage or use. Check the boxes below to select which medications/remedies from the Camp Health Center you authorize the Camp Staff to administer to your Camper, according to general labeling instructions. Note any alternate use/dosage directions in the comments below, specifying EXACTLY which medication/remedy may be used other than as directed, and how it may be used for your Camper. Acetaminophen (i.e. Tylenol) Antihistamine/allergy medicine Aspirin Ibuprofin (i.e. Motrin, Advil) Pseudoephedrine decongestant (i.e. Sudafed) Cough drops Naproxen/NSAID (i.e. Aleve) Guaifenesin cough syrup (i.e. Robitussin) Antibiotic cream Pepto-Bismol (for upset stomach/diarrhea) Sore throat spray Insect repellent/bug Spray Immodium (for diarrhea) Diphenhydramine antihistamine/allergy Aloe gel or cream (for sunburn) Laxative (for constipation i.e. Ex-Lax) medicine (i.e. Benadryl) Calamine Lotion Comments: I give permission for UME-designated Camp Health Supervisor/Monitor to administer the medications and remedies listed above. I understand the medications/remedies maintained at the Camp Health Center are only for one-time or limited-time use, and will not be provided to my Camper on a long-term or continuing basis. I understand the medications/remedies will be administered according to label directions unless I specifically directed otherwise in the Comments section above. Signature of Parent/Guardian: Date: Relationship to Camper: University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression. 4/2016

CAMPER MEDICATIONS Page 5 Camper s Name: Age: Birthdate: MEDICATION ADMINISTRATION AUTHORIZATION FORM MARYLAND 4-H CAMPS This form must be FULLY completed and signed by both the Camper s Parent/Guardian and Physician for Camp Staff members to administer the required medication, or for the Camper to self-administer medication. A new Medication Administration Authorization Form must be completed at the beginning of each camp season, or any time there is a change in dosage, use, or administration of a medication. Unless updated sooner, this form is valid for one year from the date of Physician s signature. All medications or substances authorized by this form must be handled as follows: Prescription medications must be in original pharmacy container, labeled with the Camper s name, name of medication, dosage, frequency of administration, prescription number, and prescribing physician s name and phone number. Medication label information must match the information and instructions provided on this form. Non-prescription medications, vitamins, and supplements must be in original container with instructions for use on label. Containers must contain exactly enough medication for Camper s use during scheduled duration of the Camp (NO extras ) An adult must bring the medication to Camp and give the medications to an adult staff member. Multiple medication containers for one Camper should be collected in a clear plastic bag labeled with the Camper s name. Campers who are authorized to self-carry/self-administer medication (such as inhaler, insulin, Epi-pen, etc) may carry the medication to Camp but must, in the presence of a responsible adult, show it to an adult Camp Staff member when checking in CAMPER TAKES THE FOLLOWING MEDICATIONS ON A DAILY OR ROUTINE AS-NEEDED BASIS: (Include all prescription medications and non-prescription medications, vitamins, supplements, etc. supplied by the Camper) Name of Medication Dates Taken Reason for Taking Times Taken & Dosage Route (oral, topical, etc) Special Instructions/Side effects *Note if Emergency Medication Can Camper Self-Administer? (see reverse for policy) *Copy this page if more space is needed. Physician must sign EACH PAGE listing medications. Physician s Signature Physician s Name/Title Physician s Phone Date Signed Physician s Address Stamp OVER Additional Signatures Required on Reverse University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression. 4/2016

CAMPER MEDICATIONS Page 6 Camper s Name: Age: Birthdate: PARENT/GUARDIAN AUTHORIZATION I request the authorized Camp Staff to administer medication or supervise the Camper in self-administration if authorized, as prescribed by the Physician. I certify that I have legal authority to consent to medical treatment for the Camper named above, including the authority to consent to administration of medication. I understand that my camper should bring EXACTLY the amount each medication required for the duration of the Camp, in properly-labeled containers. However, further I understand that if any medication remains at the end of the authorized period it must be picked up by an adult, otherwise it will be discarded. I authorize Camp personnel to communicate with the prescriber as allowed by HIPAA. Signature of Parent/Guardian: Date: Relationship to Camper: AUTHORIZATION FOR SELF-ADMINISTRATION / SELF-CARRY MEDICATIONS This section should be completed if medication is approved for self-administration and/or self-carry by the Camper under supervision of a Camp Staff member. Self-administration means the Camper is able to take/apply the medication without assistance, but under supervision of a Camp Staff member. Self-carry means the Camper may carry the medication with him/her during Camp activities. Self-carry of medication by Campers is permitted only for emergency medications such as inhalers, insulin, epinephrine, etc. Unless noted as self-carry, all self-administered medications will remain under control of Camp Staff designee and dispensed according to the listed schedule. All self-administered and self-carry medication must be listed on the reverse of this form. Both the Physician and the Parent/Guardian must consent to selfadministration and/or self-carry by the Camper. However, Maryland youth camp operators are not required to permit self-administration or self-carry by Campers. I consent that the Camper named above is able to self-administer the medication(s) as listed on the reverse of this form. I authorize selfadministration of the listed medication(s) by the Camper under the supervision of an authorized Camp Staff member. If indicated below, the Camper may self-carry emergency medication and self-administer as necessary. Emergency medication(s) authorized for SELF-CARRY by Camper (must also be listed on reverse of this form): Signature of Parent/Guardian: Date: Relationship to Camper: Physician s Signature Physician s Name/Title Physician s Phone Date Signed Physician s Address Stamp University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression. 4/2016