application 4-h camp leader · wear glasses, contacts, or protective eyewear? if female, any...

GENDER

APPLICATION 4-H CAMP LEADER

Camp Date: June 18-22, 2018

Return to County Extension Office by February 23rd

NAME DATE OF BIRTH AGE

PHONE

NUMBER OF YEARS IN 4-H

THIS YEAR I AM COMPLETING GRADE AT SCHOOL

TOTAL # OF YEARS ATTENDED 4-H CAMP YEARS AS A TEEN LEADER

HAVE YOU ATTENDED ANY OTHER CAMPS? (LIST)

HAVE YOU HAD ANY RESPONSIBILITIES AT ANY OF THE ABOVE CAMPS?

EXPLAIN:

LIST PREVIOUS AND CURRENT 4-H ACTIVITIES AND EVENTS YOU HAVE BEEN INVOLVED WITH:

LIST PREVIOUS AND CURRENT ACTIVITIES IN SCHOOL, CHURCH AND COMMUNITY:

LIST ALL LEADERSHIP RESPONSIBILITIES YOU HAVE HAD IN 4-H, SCHOOL, CHURCH OR

COMMUNITY:

WHY DO YOU WANT TO BE A 4-H CAMP TEEN/ Adult LEADER?

DO YOU HOLD ANY CERTIFICATES (CPR, Lifeguard, etc.)? (List)

LIST ALL SPECIAL HOBBIES AND TALENTS YOU HAVE:

PLEASE LIST AT LEAST TWO REFERENCES (not related to you). PROVIDE THEIR NAME, A DAYTIME PHONE NUMBER, AN EMAIL ADDRESS (IF AVAILABLE) AND INFORMATION ABOUT HOW THEY KNOW YOU.

Parent's Initials (if under 18)

Teen/ Adult Leader's Initials

I understand that completion of this application does not insure me a spot at 4-H Camp . 4-H Camp Teen and adult leaders will be chosen based on space, previous year's leader experience, and years of camper experience. I understand that while at 4-H Camp I am to follow all rules shared by the camp leadership team and in the 4-H Code of Conduct.

I understand that if chosen to attend camp as a Teen or Adult Leader my main purpose at camp is to ensure the safety of all campers. I understand that any issues such as but not limited to sneaking out at night, possession of drugs or alcohol, or any mistreatment of a camper, teen leader, adult leader, or staff member will lead to my immediate dismissal from 4-H Camp and transportation home will be at my/ my parents expense.

Signature of Applicant (Teen or Adult)

Date

Signature of Parent (if applicant is under 18) Date

Return to: Marion County Extension Service

416 Fairgrounds Rd Lebanon, KY 40033

Interviews will be set up as applications are received.

* * * Deadline: February 23rd * * *

University of Kentucky College of Agriculture, Food and Environment Cooperative Extension Service

4-H Camp Position Volunteer Teen Leader

HR6

POSITION DESCRIPTION: Kentucky 4-14/Youth Development Program The University of Kentucky Cooperative Extension Service

POSITION TITLE: Teen Leader

QUALIFICATIONS: Experience as a 4-14 Camper

Must undergo the Kentucky 4-H volunteer application and screening process and be accepted as a volunteer. Must be 16 years of age or older.

SUPERVISOR: County 4-H Agent and Camp Program Director

TIME REQUIRED / DURATION OF APPOINTMENT: During Camp Session

LOCATIONS: West Kentucky 4-H Camp, Dawson Springs North Central 4-H Camp, Carlisle

Lake Cumberland 4-H Center, Jabez J.M. Feltner 4-H Camp, London

SPECIFIC RESPONSIBILITIES: Teen Leaders might have the following responsibilities:

1. Along with the Adult Leader, reside in a cabin with campers. A teen leader must never be alone with campers while in the cabin. An adult must always be present when in the cabin.

2. Assist in orienting campers to the camp and program. 3. Help guide campers in making choices of classes. 4. Be on the alert for homesickness or other issues. 5. Check health and safety needs of campers. 6. Help take care of campers' personal property. 7. Help create positive attitude of campers in cabin. 8. Maintain order in cabin or group. 9. Assist campers during class periods. 10. Have a "quiet" cabin after lights are out. 11. Watch for fatigue in camp group. 12. Assist in rainy day programs by supervising games in cabin, etc. 13. Promote camper participation in all activities.

Cooperative Extension Service Agriculture and Natural Resources Family and Consumer Sciences 4-H Youth Development Community and Economic Development

Educational programs of Kentucky Cooperative Extension serve all people regardless of economic or social status and win not discriminate on the basis of race, color, ethnic origin, national origin, creed, religion, political belief, sex, sexual orientation, gender identity, gender expression, pregnancy, marital status, genetic information, age, veteran status, or physical or mental disability. University of Kentucky, Kentucky State University, U.S. Department of Agriculture, and Kentucky Counties, Cooperating.

LEXINGTON, KY 40546

(dv Disabilities accommodated with prior notification.


14. Assist campers with housekeeping responsibilities. 15. Set a good example in all you do at camp; serves as a role model to campers. 16. Report daily on progress, situation, problems and successes to County Extension Agents and

attend Staff meetings as requested. 17. Assist with program planning and evaluation. 18. Assist Camp Staff, adult leaders or Extension Agents, upon request, in such areas as classes,

meditations, flags, crafts, etc. 19. Assist Staff, Adults, and Agents in managing emergency events, e.g. severe weather, tornado

warning, missing camper. Specific tasks will be assigned. 20. Work with campers in planning and conducting such programs as flag raising and lowering and

meditations. 21. All leaders must attend camp training and orientation programs offered at the county or multi-

county level. 22. All leaders are ultimately responsible to the Camp Program Director for the camp in which they

are involved.

GENERAL RESPONSIBILITIES: A 4-H Camp Teen Leader may assist the County Extension Agent in the care and welfare of the youth from a county. Certain responsibilities may be delegated to a Teen Leader, but at no time may a teen leader substitute for an adult leader and/or Extension Agent. The teen leader is not to leave the campground without permission and prior notification from the extension agent.

County Extension Agents will assume the responsibility of recruiting Teen Leaders. Leaders should be selected upon the basis of their ability to work and cooperate with agents and other adults. They should be responsible, dependable and more interested in others than in themselves. Leaders should not be selected as a part of an awards program. They should be selected upon the basis of their ability to perform and cooperate with the total Camp Staff. Selection should be made on the following personal qualities.

Teen Leaders should:

1. Have a genuine interest in working with youth. 2. Have a sincere interest in 4-H camp. 3. Be friendly, cooperative and have a high degree of personal responsibility. 4. Possess tolerance, consideration and fair-mindedness. 5. Be sympathetic and understanding. 6. Be enthusiastic.

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Prer Si9n64ure

Revised 10/31/2016

Cooperative Extension Service Agriculture and Natural Resources Family and Consumer Sciences 4-It Youth Development Community and Economic Development

Educational programs of Kentucky Cooperative Extension serve all people regardless of economic or social status and will not discriminate on the basis of race, color, ethnic origin, national origin, creed, religion, political belief, sex, sexual orientation, gender identity, gender expression, pregnancy, marital status, genetic information, age, veteran status, or physical or mental disability. University of Kentucky, Kentucky State University, U.S. Department of Agriculture, and Kentucky Counties, Cooperating.

LEXINGTON, KY 40546 O Disabilities

accommodated with prior notification.

fi `'-ACCREDITED KEN7UCKY*

11 , CAMP*K;


4 - H Youth Dereiopment

Kentucky 4-H Camping Program 2018 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: What school does the camp participant attend?

Gender:

❑ M ❑ F

Shirt Size: (Circle One)

YS YM YL AS AM AL AXL A2XL A3XL A4XL

Birthdate:

/ /

How old will the participant be on the first day of camp?

Participant's home address: Race (check all that apply) ❑ American Indian

❑ Asian ❑ Pacific Islander

❑ White

❑ Black

❑ Hispanic

❑ Non-Hispanic

Participant's LEGAL Custodial Parents/Guardians #1 — Full Name: Home Address: Email Address: Cell/Home Number:

#2 — Full Name: Home Address: Email Address: Cell/Home Number:

Emergency Contact if above individuals are unavailable Full Name: Relationship to participant: Cell/Home Phone:

Participant's Family Ph sician Name: Address: Phone

Medical and Dietary Restrictions (list all known and reaction management):

Cooperative Extension Service Agriculture and Natural Resources Family and Consumer Sciences 4-H Youth Development Community and Economic Development


LEXINGTON, KY 40546

eks

Disabilities accommodated with prior notification.

FRONT OF INSURANCE CARD BACK OF INSURANCE CARD

Do you want to buy your camper/teen some camp gear? www.4hcampstore.com

Is your camper looking for more camping opportunities? www.4hcampevents.com

1[ ir University of Kentucky A College of Agriculture,

Food and Environment Cooperative Extension Service

-H Youth Development

CAMP USE ONLY (Healthcare Staff Review Stamp)

YES NO YES NO Had any recent injury, illness, or infectious disease? Ever had high blood pressure? Have a chronic or recurring illness/condition? Ever been diagnosed with a heart murmur? Ever been hospitalized? Ever had back problems? Ever had surgery? Ever had problems with joints, knees, or ankles? Have frequent headaches? Have an orthodontic appliance brought to camp? Ever been knocked unconscious? Have any skin problems (rash, acne)? Wear glasses, contacts, or protective eyewear? If female, any abnormal menstrual history? Ever had frequent ear infections? Had problems with diarrhea or constipation? Ever passed out, dizzy, or chest pain during exercise? Had mononucleosis in the past 12 months? Ever had an eating disorder? Have diabetes? Had problems with sleepwalking? Have asthma? Ever had seizures? Have a history of bed wetting? Ever had emotional difficulties? Have severe allergies? Carry an epi-pen or inhaler? Explanation of YES answers:

Behavior or Medical History Are there any other behavior needs, accommodations, or information which the staff should be made aware of to provide a better camp experience for the participant?

Immunization Records Is the camp participant up-to-date on immunizations as outlined by Kentucky law required for enrollment in public or private 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? l:i YES (Attach a copy — front and back — of the insurance card in the boxes below.) 1:1 NO (No worries! Camp provides an excess medical insurance coverage in the event of injuries or illnesses.)

Cooperative Extension Service

Agriculture and Natural Resources

Family and Consumer Sciences

4-H Youth Development

Community and Economic Development

Educational programs of Kentucky Cooperative Extension serve all people regardless of economic or social status and will not discriminate on the basis of race, color, ethnic origin, national origin, creed, religion, political belief, sex, sexual orientation, gender Identity, gender expression, pregnancy, marital status, genetic information, age, veteran status, or physical or mental disability. University of Kentucky, Kentucky State University, U.S. Department of Agriculture, and Kentucky Counties, Cooperating.

LEXINGTON, KY 40546


University of Kentucky College of Agriculture, Food

College Environment Cooperative Extension Servire

4 , fl linah Derviopmera

CAMP PARTICIPANT'S NAME:

AUTHORIZATIONS/RELEASES This is a legal document. You must read and understand it before signing it.

Consent to Treat: The health history reported on page one and two are correct and complete to the best of my knowledge. The person herein described has permission to engage in all camp activities except as noted. 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 out of camp.

Media Release: I grant the Kentucky 4-H Program and the University of Kentucky, and persons acting through them, the right to use, reproduce, assign, and/or distribute photographs, films, videotapes, and sound recordings of 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.

Code of Conduct: I have read and discussed the Code of Conduct with my participant. We (parent/guardian and participant) understand and agree to comply with the guidelines. Violations may result in the loss of privileges, removal from camp with no refund, assessment of a damage fee 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

Permission to Participate: I understand that my child's participation recognize that programs are designed and my child will choose his or her level involved and permission to participant

in the Kentucky 4-H Summer Camping Program is based on the challenge to use experienf al, engaging teaching techniques, but that my child's participation

of participat'on in any activity. The camp activities listed below require from the parent/guardian. Place a check indicating YES or NO next to each

by choice philosophy. I is purely voluntary, always,

acknowledgement of the risks activity, and then sign below.

YES NO YES NO High Ropes Horses (WKY only) Low Ropes Cave (LC only) Archery Firearms

Pick-up Release: It is my responsibility to arrange to pick up my child/children upon return from camp. There will be no exceptions relationship to the child. Please inform everyone approved by you on this release that he/she must present child will be released. Parents, Guardians, and Emergency Contacts listed on page 1 are automatically authorization. In addition to the parents/guardians listed on page 1, the following individuals are granted

NAME: RELATIONSHIP Phone/Cell#

a driver's

permission assumed

to this policy regardless of license or photo ID before the

to have pick up to pick up my child



Assumption of Risk and Release of Liability: I acknowledge that there are certain risks, hazards, and dangers, including the risk of physical injury, disability, or death and risk of loss of use or damage to my personal property as a result of 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, 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.

Participant Signature: Date:

Parent/Guardian Signature: Date:

Cooperative Extension Service Agriculture and Natural Resources

Family and Consumer Sciences 4-H Youth Development Community and Economic Development


LEXINGTON, KY 40546 so


application 4-h camp leader · wear glasses, contacts, or protective eyewear? if female, any...

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