DELEGATE APPLICATION FORM – 2016 4-H ISSUES CONFERENCE

County:

District:

Name:

Phone Number:

Address: Delegate’s Email:

City:

Zip:

Race & Ethnicity (Circle): Caucasian | African-American | Asian | Native American/Islander | Multi-Racial | Other Non-Hispanic | Hispanic

Gender (Circle One)

Male Female

Grade (Circle One)

Sophomore Junior Senior Adult Other: ________________________

Preferred Shirt Size

Small Medium Large XLarge XXLarge 3XLarge

Action Group Preference (first year participants)

First Choice _____ Second Choice _____ (You MUST select three choices) Third Choice _____

SPECIAL: (returning participants)

I’m submitting this application for “Issues Conference – Level 2”. Please verify the following: ___ I have attended 4-H Issues Conference within the last 2 years. ___ I will bring the required one-page essay describing an issue in my county I would like to address and why.

Guardian’s Name: Guardian’s Signature:

Emergency Phone: Other Phone:

To be completed by Agent. Please indicate the desired treatment of this application.

_____ Consider as part of the county quota _____ Accept on a space available basis Delegates should return this form and registration fee to their County 4-H Agents. Make checks out to “Kentucky 4-H Foundation” and put “Issues Conference” in the Memo Line. Payments are due by the deadlines as established according to the Kentucky 4-H Late Fee & Payment Policy. Agents should enter all registrations (youth, volunteers, agents & staff) online and submit the appropriate fees by the deadline.

4-H Participant Information/Enrollment Form (NOT FOR RESIDENTIAL CAMP)

Note: The form must be completed by the participant and/or parent or guardian in order to participate in the 4-H program. All items must be completed, even if the response is not applicable – indicate by using N/A (i.e. no health insurance). Failure to complete this form in its entirety will result in the person being ineligible to participate in 4-H activities. Please print in blue or black ink to allow for photocopying.

Name: County/District: Last First

Address: Birth date: Age: Youth Female

Adult Male

City: State: KY Zip: Email: Home Phone: Farm: ☐ Yes ☐ No

Race: ❑Asian ❑White ❑Black ❑American Indian ❑Hawaiian & Pacific Islander ❑Hispanic ❑Non-Hispanic Grade:

Emergency Contact #1: Phone H W C Phone H W C

Emergency Contact #2: Phone H W C Phone H W C

Name of Family Doctor: Doctor’s Phone:

Health Insurance Company: Policy #:

Name of Policy Holder/Relationship to Participant: Member ID:

HEALTH HISTORY

Does the participant have, or at any time has had, any of the following? Check “Yes” or “No” to each item. Please explain any “yes” answers (noting the number of the item) in the space below or on an additional sheet if necessary. Reporting conditions will not prevent a person from attending and will be kept confidential.

Yes No 1) Asthma ………………………………

2) Bronchitis………………………………

3) Convulsions……………………………..

4) Diabetes…………………………………

5) Ear Infection…………………………….

6) Fainting………………………………….

7) Heart Condition…………………………

8) Headaches………………………………

9) Hypoglycemia…………………………...

10) Serious Allergy to Insects…………...…

11) Wear Glasses/Contacts………………

12) Other Conditions………………………

13) Drug Allergy (please explain) ………

14) Food Allergy (please explain) ………

15) Other Allergy (please explain) ……….

Please Explain Any “Yes” Responses:

List and explain any restrictions (dietary, physical, etc):

The following over the counter medications may be administered to my child without contacting me:

Antihistamine Pill Antacid Ibuprofen (Advil) Hydrocortisone Cream

Acetaminophen (Tylenol) Decongestant Dramamine Polysporin (topical antibiotic)

MEDICAL TREATMENT All information provided on this form is correct and complete to the best of my knowledge. This person has permission to engage in all events and activities. I hereby give permission to the event designee to provide routine health care, administer prescription and over the counter medications as noted and seek emergency medical treatment if warranted. I agree to the release of all records necessary for medical treatment, billing or insurance. In the event I cannot be reached in an emergency, I give permission to the attending physician to secure and administer treatment, including hospitalization. SIGNATURE OF PARENT/PARTICIPANT: DATE:

PUBLICITY RELEASE I hereby grant the 4-H program, University of Kentucky and their agents, the right to use, reproduce, assign and/or distribute still pictures, video and sound recordings of myself or my minor child without compensation for use in promotion, advertising, educational publications or online content.

SIGNATURE OF PARENT: NO, I do not permit.

Revised 9/1/2016

4-H Youth Development CODE OF CONDUCT FORM (NOT FOR RESIDENTIAL CAMPS)

All 4-H members and family/friends associated with 4-H members must respect the individual rights, safety and property of others and adhere to this Code of Conduct. A 4-H member may be prohibited from participating in a specific event/program if the participation by the individual poses a danger to the 4-H member and/or others. The following guidelines are designed to make all 4-H events safe, meaningful, and satisfying to youth and others attending.

WHILE ATTENDING ALL 4-H MEETINGS, PROJECTS, PROGRAMS, ACTIVITIES AND EVENTS: Each 4-H participant is expected to attend all planned sessions, workshops, field trips, and meetings of the event, and to be

in appropriate dress. Dress codes will be specific to individual events. Delegation chaperones and/or volunteers are

responsible for ensuring that members participate in all aspects of the planned program activities.

The possession and use of alcoholic beverages, tobacco products, and/or drugs (except for medications prescribed to the

participant by a licensed physician) are strictly prohibited. Delegation chaperones and/or volunteers shall limit use of tobacco

products to designated areas.

Setting off fire alarms, tampering with fire extinguishing and other emergency equipment are strictly prohibited.

Gambling of any type is strictly prohibited.

Obscene, discriminatory and/or inappropriate language, roughhousing, and insubordination are prohibited at all times.

Respect toward others and facilities shall be demonstrated. Bullying, harassment of others or destruction of property shall

not be tolerated. Bullying and harassment can include the use of social media.

Display of overly affectionate or inappropriate attention between participants is strictly prohibited.

Technological equipment (including but not limited to cell phones, laptops or mp3 players) shall not interfere with the program

and may not be allowed in certain situations.

Each county may adopt additional Code of Conduct guidelines.

WHILE ATTENDING OVERNIGHT CONFERENCES, CAMPS, AND EVENTS, THE FOLLOWING WILL ALSO APPLY:

All participants are to be in their assigned area at curfew and comply with quiet hours, lights out, and other rules of the event.

No member or volunteer may leave the grounds without the permission of the conference director or adult in charge. An adult

shall accompany a 4-H member any time he/she leave the grounds. Adults shall notify another adult in the delegation before

leaving the grounds.

At overnight events, only Conference participants may be in sleeping areas. Lounges or common areas may be used only

for working committees and social activities.

Room service such as phone calls, food, laundry, or others shall not be permitted without chaperone permission.

Any violations of this Code of Conduct shall be reported promptly to the adult in charge of the delegation/program and to the person in charge of the event. The person in charge of the event shall have the final responsibility for disciplinary action. Failure to comply with the Code of Conduct by 4-H’ers and family/friends associated with the 4-H participant may result in penalty, including, but not limited to, the following:

Sent home from the activity or event at his/her own expense

Barred from participation from future 4-H events

Assessed the cost of damages for destruction of property

Released to nearest law enforcement authority

Termination of 4-H membership

I, , have read the Code of Conduct and agree to abide by its rules. (Print Name)

I understand that infraction of this Code of Conduct will result in any or all of the penalties listed above.

Member/Volunteer County

Parent/Guardian Date

2016 4-H Issues Conference Action Groups

Dear 4-H Issues Delegate: Below are the 2016 4-H Issues Conference Action Groups. Please review each Action Group description. Delegates will need to select THREE options! Every effort will be made for you to receive one of your three choices. *Some groups may be eliminated due to low interest at the close of registration. You will be notified of your selected action group 1-2 weeks before the actual conference. At that time, you should prepare a folder/binder of materials related to topics around your action group. This should include print outs of things that you think matter when discussing your assigned topic! These could include current events in your community, national and state statistics, and relevant information accessed from the Web. You should be prepared to discuss issues related to your topic when you arrive at the conference. A. Preparing for School & College

Have you made your post-secondary plans yet? Do you know where you are going to find the financial aid, scholarships and money you need to get through college? Are you going for a 2 year degree, 4 year degree, Master’s, Ph.D. or something else entirely? This action group is here to help you develop ways to keep you and your fellow students from being run over by the college prep train! Group members will:

• Discuss post-secondary options that are available to current high school students.

• Talk about potential jobs and how to receive the best preparation for those jobs when you get out of high school/college.

• Determine how students are preparing for post secondary success in work or college in your community.

• Develop a community based action plan that addresses the issues of preparing for school, college and post-secondary success!

B. Environment & Agriculture Issues

Are you from a farming community? Have ever debated being vegetarian, vegan or living a sustainable lifestyle? Do you believe agriculture and environmental issues are important? Do you wear clothes or eat food?! If so, you are impacted by agriculture, the environment and the natural world! In this action group, members will:

• Discuss hot topic and important issues surrounding agriculture, environment and the natural world.

• Identify issues related to this topic that are important in their communities and towns.

• Develop a community based action plan that addresses the selected topics related to the environment and agriculture in their community.

C. Dealing with Teen Stress

Are you on stress overload? School, sports, relationships, family, church, friends…how do you handle it all? This group focuses on teenage stress and how it can be addressed in your community. Group members will:

• Discuss types of stress and how people deal with it.

• Determine what types of stress are most common in their school and community.

• Develop a community based action plan that addresses the issue of teen stress.

D. Demonstrating Character & Ethics

Do you stand strong in what you believe in? Do you fight for what is right? Do you feel a responsibility to your community to preserve its values and integrity? Do you want to improve your community and the world around you? Then you may be perfect for this action group. Group members will: • Exploring the true meaning of Character and Ethics

• Discuss how the topic of character and ethics apply to then, their relationships and their community.

• Discuss how they can utilize their learned skills to improve the community

• Develop a community based action plan that addresses the issue of character and ethics in their town or community.

E. Addressing Bullying

Have you ever seen an incident of bullying taking place? What creates a “bully”? Do you have suggestions for addressing bullies in your communities? For Kentucky communities to thrive, there have to be people willing and able to address this issue. In this action group, members will:

• Discuss the characteristics of bullying, where and how it occurs.

• Review incidences of bullying in communities and the short & long-term effects.

• Brainstorm ways that bullying can be addressed in a proactive way.

• Create a community based action plan that addresses the issue of bullying.

F. Special Action Group – Civic Engagement - Level 2 (returning Participants) To be selected for this Action Group, participants must be a returning Issues Conference participant. Civic Engagement Action Group participants will be working on advanced topics for youth community engagement and will develop an action plan for their community issue. Civic Engagement/Issues Level II delegates must bring a typed one-page essay describing a personal goal they would like to see achieved dealing with an issue in their home community to the Conference. Emphasis should be on how other groups and organizations could work together to achieve the goal. Must be of 4-H age and have attended Issues Conference. Revised September 2016

2016 4-H Issues Conference DRAFT SCHEDULE

Thursday, November 17, 2016 (all times are Eastern Standard Time) 5:30 – 6:30 PM Arrival and Registration – Lobby 6:30 – 7:15 Welcome to Issues Conference! Get Acquainted – Multi-Purpose Room 7:15 – 7:45 Committee Meetings & Civic Engagement Project (Room Set Up – Open/Chairs In Stacks on Sides) Assemblies and Good Morning Jabez – Multi-Purpose Room Operations – Multi-Purpose Room Talent Show – Feltner Room Inspirations – Kidwell Room Hospitality Committee – Multi-Purpose Room 7:45 – 8:15 Community Gathering – Multi-Purpose Room Posting of Colors Pledges

Thought for the Day Welcome from your Chairs! Planning Committee Introductions My Story The Issues Impact You We Have Issues Conference Goals Group Living/Rules 8:15 – 8:45 Action Group Activity What is the Process? 8:45 – 10:00 Action Group Meetings Meet in assigned locations 10:00 Refreshments – Popcorn & Drinks Cafeteria 10:30 Agents, Adults, Committee Meeting – Lobby (by fireplace) Chuck Stamper, Facilitating

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10:30 Preparing for the Weekend! – Multi-Purpose Room Ice Breaker, Review of Schedule, Hospitality Update 11:00 Delegates in Their Own Room, Lobby or Covered Deck 11:00 Lobby Closed – Lights Out Issues Planning Team will debrief in the Lobby Friday, November 18, 2016 8:00 – 8:30AM Breakfast Served in Dining Hall 9:00 – 9:30 Community Gathering – Multi-Purpose Room Good Morning Jabez

Posting of Colors Pledges

Thought for the Day What is a Fiscal Court and Why is it important in local issues? How to Present a Proposal (Not!)

9:30 – 10:30 Group Activity – Where Do You Stand? 10:30 – Noon Action Groups Meet (break as appropriate) Noon – 1:00 PM Lunch 1:00 – 3:30 Action Groups Meet (break as appropriate)

Case Study 3:30 – 4:00 Break – Popcorn & Drinks in Front Lobby 4:00 – 5:30 Open Recreation/Crafts Inspirations Committee, Facilitating 5:30– 6:00 Networking/Prepare for Dinner 6:00 – 7:00 Dinner 7:00 – 8:00 Community Gathering “The Sticky Wall” Building Youth Adult Partnerships 8:00 – 9:00 Actions Groups Meet

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9:00 – 10:00 Talent & Variety Show Talent Show Committee, Facilitating 10:00 Ice Cream Social 11:00 Delegates in Their Own Rooms, Lobby or Covered Deck 11:00 Lobby Closed – Lights Out Issues Planning Team will debrief in the Lobby Saturday, November 19, 2016 8:00 – 8:30 AM Breakfast in the Dining Hall 8:30 – 8:45 Community Gathering in Dining Hall Good Morning Jabez

Posting of Colors Pledges

Thought for the Day 9:00 – Noon Actions Groups Meet (break as appropriate) How do we get there? Develop and Practice Presentations Noon Lunch 1:30 – 2:30PM Community Gathering

Action Group Presentations – Actions groups will make presentations to a mock Fiscal Court which has $25,000 to award to youth led projects. Action groups must adhere to a strict time limit of ten minutes per presentation.

2:30 – 2:40 10 Minute Break 2:40 – 3:30 Continue Community Gathering 3:45 -5:30 PSA’s – Planning, practicing, refining

Public Service Announcements (PSA’s) – A short 2-3 minute “commercial” that talks about your action group topic. These are not related to your Fiscal Court presentations and should consist of a broader message that brings awareness to your action group subject.

6:00 – 7:00 Dinner 6:30 Planning Committee Meeting 7:00 – 8:30 PSA’s, Finish/Filming

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9:00 – 10:30 Costume Dance “Neon/Glow” Board Games Movie 10:30 Delegates in Their Own Room, Lobby or Covered Deck 11:00 Lobby Closed – Lights Out Issues Planning Committee will debrief in the Lobby Sunday, November 20, 2016 8:00 AM Be Packed Wear Issues ’16 Shirts 8:00 – 8:30 Breakfast Served in Dining Hall 8:45 – 9:00 Inspirations (optional) 9:00 – 9:15 Group Picture/District Pictures Issues Committee Total Group Districts 9:30 – 11:00 Community Gathering Good Morning Jabez

Posting of Colors Pledges

Thought for the Day Teen Conference Invitation PSA’s - Viewing Action Group Results Closing Slide Show “The Places You’ll Go” – Conference Co-Chairs

Depart for Home