2017 Placer County 4-H

Summer Camp @ Woodchuck Flat Campground, Cisco Grove July 24-29, 2017

How to Register: Complete and mail or hand deliver the following forms to:

Placer County 4-H Summer Camp, 11477 E Avenue, Auburn CA 95603

Registration Form (page 4)

Activity Permission Slip (page 5)

Medical Release Form (page 9 &10) completed front & back, signed by parent/guardian

Camp Code of Conduct

Camp fees—checks payable to: Placer County 4-H

Fees for camp $125.00

4-H Enrollment Forms: I f you are NOT enrolled w ith a P lacer County 4-H CLUB this enrollment year of 2016-2017 you must complete the 4-H Enrollment Forms in addition to the Camp Registration. These forms are available from the Placer County 4-H Office or online at: http://ucanr.org/placer4hsummercamp

Due to the popularity of this camp, a waiting list is anticipated. Please notify the 4-H office as soon as possible if youth will not be able to attend as planned. Youth enrolled in 4-H only for camp will need to notify the office by June 19, 2017 in order to receive your enrollment fee of $40 back. The $125 camp fee will be refunded for all youth who do not attend.

Eligibility Requirements:

4-H members aged 9 years old (by December 31, 2016) to youth turning 19 years old in 2017 are eligible to attend camp. There are no other requirements other than being a 4-H member. Record books are not a requirement and Community Clubs may not place any restrictions on their members attending camp.

Volunteer Adults staying overnight must be 25 years old or older and be a Certified 4-H Volunteer which requires a DOJ live-scan background clearance (fingerprinting) and 4-H Orientation certification.

Questions:

Should you have additional questions, call the Placer County 4-H Office (530) 889-7386 and speak with Shannon Kane, the 4-H Community Education Specialist.

2017 Placer County 4-H Summer Camp Information …...

How is Camp Organized:

Camp is supervised by adults, one adult to each eight campers. Led by two adult Camp Directors, two Junior Camp Directors and a Junior Camp Staff of twenty four Tribe Leaders. Tribe Leaders are older 4-H members that have been to camp before and are experienced leaders. Campers will be divided into six tribes of boys and girls of mixed ages. Tribe leaders will be sleeping in each tent. Our entire staff is volunteer and we look forward to providing an enjoyable, productive and rewarding camp experience for your children.

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It is the policy of the University of California (UC) and the UC Division of Agriculture & Natural Resources not to engage in discrimination against or harassment of

any person in any of its programs or activities (Complete nondiscrimination policy statement can be found at http://ucanr.edu/sites/anrstaff/files/169224.pdf )

Inquiries regarding ANR’s nondiscrimination policies may be directed to Linda Marie Manton, Affirmative Action Contact, University of California, Davis,

Agriculture and Natural Resources, One Shields Avenue, Davis, CA 95616, (530) 752-0495.

2017 Placer County 4-H Summer Camp Information - Continued...

2017 Camp Adventures:

Each camper will receive a tee shirt and group camp picture.

On Monday, campers w ill arrive before lunch, have a special program in the afternoon, take a group picture, get acquainted, hand-crank ice cream for dessert, have craft time with a campfire after dinner.

Tuesday through Friday, will be filled w ith camping adventures including, hiking, swimming at Sterling Lake, kayaking, canoeing, sports, crafts, a ropes course, archery, hands-on learning sessions with rockets, campfire cooking, boat & bridge building, robotics and more. Evenings will feature astronomy, campfires, a talent show and special activities on Friday night.

On Saturday, campers and staff prepare to return home, participate in the friendship circle, write in each others camp books, and have brunch.

Meals and Snacks Provided:

The first meal is lunch on the first day. Each day thereafter includes three good home cooked meals plus healthy snacks available at all times. Please let us know of any special dietary needs. Also, please leave snacks and candy home as they are an attraction for the local varmints.

Note: Any donations of fresh vegetables and fruit, especially melons, would be greatly appreciated. Please call the 4-H office at (530) 889-7386.

Transportation To Camp:

Transportation: We will NOT have bus transportation for camp. Parents of campers will be responsible to get them and their belongings to and from camp. Carpooling in a 4-wheel drive or high clearance vehicle is recommended. We WILL NOT be arranging carpools. Please attend the date to be released later in 2017 Orientation Meeting to network with other parents to arrange car pools if possible.

How to get to camp: From Auburn, travel East on Interstate 80 and turn off at the Cisco Grove exit. This exit is after the Eagle Lakes exit and before the Kingvale exit. Go over the top of I-80 at the Cisco Grove exit and turn left where the road tee’s. You will now be driving to the front gate of Cisco Grove Campground (a private campground). You will go approximately 100 yards and turn right onto Rattlesnake Road. The road will be marked with a 4-H emblem. It is the road that goes to Lake Sterling. Travel 3+ miles and watch for our meadow and tents on your right. PLEASE NOTE: Rattlesnake Road is a ONE LANE road, go slow and use caution.

Camp Facilities:

Campers will sleep in tents with plywood floors. Girls on one side of camp; boys at the other end of camp. Each side of camp has their own bathrooms. The permanent building in the center is the kitchen. Behind the kitchen are showers. All power is provided by a generator, and water is provided from our well.

We have emergency communication by cellular phone. The nearest phone is three miles away. Program staff at the 4-H office have our cellular number and can forward emergency messages to us. The first aid center is located near the craft area. Medical personnel will be present.

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BRING: DO NOT BRING:

Warm sleeping bag, pillow, and a pad, cot or an air mattress to sleep on Warm blanket or two – A must! I t’s cold in the evenings

Cell Phones, I-Phones, Blackberries, Etc. Camp emergency number will be provided to youth families

Flashlight with extra batteries Money – there is no place to spend it

Sturdy closed toed shoes; tennis shoe or hiking shoe strongly recommended; sandals are acceptable for showers

Shaving cream, water guns or balloons

Insect repellent Immodest attire

Hooded sweatshirt Fireworks or any type of ignition device that may cause a spark or flame. This includes: propane hair dryers, curling irons, matches & lighters.

Swim suit (modest, and t-shirt to cover while hiking) & beach towel

Valuables

Towels & washcloths Food/snacks/candy (see below)

Chap stick Pocket knives, No knives of any kind

Sunscreen Electronic devices , I-pods, MP3 players, etc.

Toiletries: tooth brush, tooth paste, soap, etc. Masks or face paint

Old clothes, could be hot as well as cold

All medications must be clearly marked and given to nurse upon checking in at camp.

2017 Placer County 4-H Summer Camp Information continued

*Keep this suggested packing list* All belongings to be marked with your name so we are able to reunite lost things with owner.

Please DO NOT bring any kind of snack or candy to camp as the smell can attract varmints or possibly even bears! Lots of nutritious snacks will be provided along with good home cooked meals. If you have food restrictions, you may bring your snack in a one-quart zip lock bag with your name on it. Give it to the Camp Directors when you arrive at camp, and it will be stored in the camp kitchen for your use.

Any questions please call the 4-H Office (530) 889-7386.

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2017 PLACER COUNTY 4-H SUMMER CAMP REGISTRATION (Submit one registration form per camper.)

Name: ____________________________________________ Club Name: ___________________(if applicable)

Male or Female (circle one) Age:________ Grade completed:__________ Ethnic Origin (optional): ___________

Address: ___________________________________________________________________________________

City: __________________________________________ State: ________ Zip Code ____________________

E-mail (for confirmation and updates):_______________________________________________________________

Home Phone Number: (_____) _________________ Parent Work/Cell Phone (_____) ___________________

Alternative Emergency Contact Information:

Name:__________________________________________ Phone (_____) _________________ Relationship to camper:___________________________________

I request to be in a tribe with ______________________________________________ (name of fellow camper)

PLEASE NOTE: Tents will be divided into age groups. Tribes will be mixed ages. Requests will be accommodated when possible.

Do you have severe reactions to wasp or bee stings? Yes or No (circle one)

If so, do you carry a bee sting kit? Yes or No (circle one)

Please describe your child’s reaction when stung:____________________________________________________

Please use the back of form to address any special concerns.

Parents: Camp is not fun if your child is sick - so send them ONLY if they are healthy. Please CIRCLE the t-shirt size needed: Youth: L Adult: S M L XL

Page 4

Paste a

Current Photo

Here

This helps our volunteers recognize your child.

2017 PLACER COUNTY 4-H SUMMER CAMP REGISTRATION

Activity Permission Slip By checking the box(es) below,

I give permission for my child________________________________________________ (print child’s first & last name)

to participate in the activity at Placer County 4-H Summer Camp.

Archery

High Ropes Course

Kayaking & Canoeing

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Form Revised 7/1/2016

Youth Treatment Authorization Form (PAGE SUBMITTED TO AND RETAINED BY THE 4-H CLUB/UNIT LEADER) This Treatment Authorization Form is authorized for all 4-H Youth Development meetings and activities during the dates specified below. (Please Note: This information must be updated annually)

First Name Last Name Club/Unit Name

From: July 1, 2016 to December 31, 2017 County and State

EMERGENCY CONTACT INFORMATION:

First & Last Name: Home/Work/Other Phone:

Relationship: Cell Phone:

While my child is attending or traveling to or from this 4-H function, I HEREBY AUTHORIZE THE 4-H ADULT VOLUNTEER OR 4-H STAFF MEMBER, or in his/her absence or disability, any adult accompanying or assisting him/her, TO CONSENT TO THE FOLLOWING MEDICAL TREATMENT FOR SAID MINOR:

Any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Practices Act, California Business and Professions Code Section 2000 et seq.; or any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered by a dentist licensed under the provisions of the Dental Practices Act, California Business and Professions Code Section 1600 et seq.

This authorization is given pursuant to the provisions of California Family Code Section 6910. This authorization shall remain effective until my child completes his/her activities in this program unless sooner revoked in writing. I understand that as a parent/guardian, I will be responsible for the cost of any service or treatment provided not covered by the 4-H Accident/Sickness Insurance Program sponsored by UC Cooperative Extension.

AUTHORIZATION AND CONSENT AND RELEASE

I hereby certify that my child is in good health and can travel to and participate in all functions of the 4-H Youth Development Program as described above. I am the parent/guardian having legal custody of the youth member named above as stated under California Family Code Section 6550. I understand it is my responsibility to keep the information on this form updated (including Health History) by contacting the County 4-H Office.

_________________________________________________ Signature of Parent/Guardian Date

NON-CONSENT

I do not desire to sign this authorization and understand that this will prohibit my child from receiving any non-life threatening medical attention in the event of illness or accident.

_________________________________________________ Signature of Parent/Guardian Date

University policy and the State of California Information Practices Act of 1977 require the following information be provided when collecting personal information from you: The information entered on this form is collected under authority of the Smith-Lever Act. Submission of the medical data is voluntary. However, a signature is required on one or the other of the two signature lines above. Failure to provide the medical information and authorization may result in our inability to provide necessary medical treatment. You have the right to review University records containing personal information about you, with certain exceptions as set forth in policy and statute. Copies of University policies pertaining to the collection, use, or release of personal data are available for your examination from the local UCCE County Director, 4-H Youth Development Advisor, 4-H Program Representative or the Associate Director of 4-H Program & Policy at University of California, Division of Agriculture and Natural Resources, California State 4-H Office, 2801 Second Street, Davis, CA 95618-7774, (530) 750-1334, ca4h@ucanr.edu. Only your own records are open to your review.

Form Revised 7/1/2016

Health History Information (PAGE SUBMITTED TO AND RETAINED BY THE 4-H CLUB/UNIT LEADER; SHRED AFTER THE PROGRAM YEAR) (please attach extra page if more space is needed)

/ / First Name Last Name County Date of Birth

Date of last Tetanus Vaccination: Not Sure None

Please check over-the-counter medications that may be administered: Tylenol Ibuprofen Cough Syrup Decongestant Dramamine Antacid Polysporin

Hydrocortisone Benadryl Other:

Please identify if this participant has any health conditions that are important for program staff to know in order to maximize participation and ensure safety and well-being?:

Or check this box if no information needs to be shared

Please list all current medications: Name of Medication Dosage Times Taken

Please identify any allergies including allergies to food, medications, and drug reactions:

Please include any additional remarks and special instructions to better assist emergency service personnel.

Please list any additional assistance the youth will need in order to participate in this program or activity. Note: in some cases, a Doctor’s note may be required to confirm the request.

Please explain any “Yes” answers on this page.

Yes No

Does the youth have any current emotional or behavioral difficulties that would be helpful for us to know about? Are there any ways of responding to the youth’s negative moods or feelings that you found to be effective? Would you like to share any significant life or family events that will help us support the youth’s current emotional state?

The following guidelines are designed to make everyone’s experience at 4-H camp satisfying to all attending. This means that all youth members, adult volunteers, and 4-H YDP staff, shall adhere to the core values of the University of California 4-H YDP, respect the individual rights, safety, and property of others

The following guidelines are designed to make everyone’s experience at 4-H camp satisfying to all attending. This means that all youth members, adult volunteers, and 4-H YDP staff,

. While you are attending 4-H Camp, you are representing 4-H and the University of California.

shall adhere to the core values of the University of California 4-H YDP, respect the individual rights, safety, and property of others

While attending 4-H Camp the following will apply:

. While you are attending 4-H Camp, you are representing 4-H and the University of California.

1. Everyone is expected to participate in all activities, evening program, flag ceremony and the camp fire program. 2. All campers and camp staff must be in their assigned tents by lights out and during rest period and must remain quiet. If an emergency arises the camper

must be escorted by their tribe leader. 3. All campers, camp staff and 4-H YDP Staff must abide by the 4-H Dress Code. It will be strictly enforced. A name badge MUST be worn at all times. No

spaghetti strap shirts and no daisy duke shorts. Flips-flops may only be worn during showering, swimming or canoeing. 4. The possession and use of alcoholic beverages, tobacco products, and drugs (other than prescription medication) is prohibited. Note: This will result in

immediate dismissal. 5. Setting off fire alarms or tampering with fire extinguishing equipment or other emergency equipment is prohibited. Note: This will result in immediate

dismissal from camp. 6. Gambling and betting by adults and youth representing 4-H is prohibited. 7. Obscene and discriminatory language, roughhousing, and insubordination will not be tolerated. 8. Youth members and volunteers will demonstrate respect for one another at all times. 9. Displays of affection between participants are prohibited. 10. Participants are not allowed in the sleeping areas of members of the opposite gender. 11. No member or volunteer may leave camp unless permission is secured from the Camp Director or the Camp Chairman.

• For all off-site activities everyone must sign out and upon returning must sign back in. All campers must be accompanied by adult leaders and junior counselors.

12. No Cell Phones, I-Phones, Blackberries, electronic devices, IPods, MP3 players, pocket knives or knives of any type shall be in camper’s possession. (Adults may use cell phones, IPhones, and/or knifes, pocket knives as deemed necessary.)

Penalties for Infractions: Infractions of the 4-H Camp Code of Conduct must be reported immediately by anyone observing them to the adult/JC in charge of the activity. For serious infractions, an Incident Report will be completed and the parent/guardian will be notified immediately by the Camp Director and the IR will be submitted for review to the 4-H YDP Staff and Placer County Leaders’ Council. Penalties may include any or all of the following: • Sending the participant home or barring the participant from future 4-H events • Assessing the participant the cost of damages and repairs for damage or destruction of property • Releasing the participant to the nearest law enforcement agency and/or the proper authorities • Termination of 4-H membership Signature of Member:____________________________________________________ Date:______________________ Signature of Parent/Guardian:_____________________________________________ Date:______________________