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11
Cooperative Extension Service l Tanana District Office l P.O. Box 758155 l Fairbanks, Alaska 99775-8155 l 907-474-1530 Tanana District 4-H News Published by the University of Alaska Fairbanks Cooperative Extension Service in cooperation with the United States Department of Agriculture. UA is an AA/EO employer and educational institution and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination. June 2018 Editor: Marla Lowder, 4-H & Youth Development Agent, [email protected] Layout & Design: Ronda L. Boswell, 4-H Administrative Assistant, [email protected] 4-H: Your first class at UAF! I want to take a moment and say thank you to all for your patience with my crazy schedule and such over the past few months. Sometimes, I don’t know if I am coming or going. It seems like I get caught up at one job and then get behind in the other and then vice versa. Then with my travel schedule added into that and the state horse contest prep, it has taken a lot of time. So, I really do appreciate your patience and support through this. So, the big things coming up are all the camps and clinics and shows. You can find more information inside the newsletter. I have sat and pondered over the past couple months on plans and such for how we can build our program back up. We have a great program and you all are great. I would just like to add to it. How do we get more leaders and ones with a variety of different projects? Then, how do we get more members? I feel the leaders we have are taxed already for the most part and feel we need more of them before we can get the youth in those project areas. I am looking for any thoughts and maybe people to help go out and reach the new or next generation. Thoughts from you are appreciated. I hope you all enjoyed this past spring. Have a wonderful June. Marla’s Roundup •••••• June •••••• •••••• July ••••••• 1 ����������� Camp Counselor Applications Due for Cloverbud Camp 4 ����������� Teen Club meeting, 6 p.m. 5 ����������� Livestock Council meeting, 6:30 p.m. 8-10 ��� Livestock Clinic and Jackpot Show 9 ����������� Horse Council meeting, 10 a.m. 12�������� Leaders Council meeting, 6:30 p.m. 14�������� Junior Jamboree Camp Counselor Training, 5:30 p.m. 14-16��� Equine Clinic and Schooling Show 15�������� Registration Deadline for Junior Jamboree Camp 17�������� Father’s Day 18�������� Teen Club meeting, 6 p.m. 25-28���Junior Jamboree Camp ••••••••••• What’s Inside ••••••••••• 2 ����������� Teen Club meeting, 6 p.m. 3 ����������� Livestock Council meeting, 6:30 p.m. 4-5 ����� Independence Day Holiday (4-H office closed) 9 ����������� Registration Deadline for Cloverbud Day Camp 10�������� Leaders Council meeting, 6:30 p.m. 11-13��� Alaska Youth Livestock Camp and McCullough Fitting Clinic 14�������� Horse Council meeting, 10 a.m. 16-18��� Cloverbud Day Camp 31�������� Sewing Challenge, noon 2 ����������� Leaders and Members — Have You Enrolled Yet? 2 ����������� Ready, Set ... Let’s Camp! 2 ����������� Equine Clinic and Schooling Show Set 3 ����������� Get Ready for the Fair! 4 ����������� Livestock Clinic and Jackpot Show — Schedule Set 5 ����������� Market Livestock Update — Important Dates 6 ����������� Alaska Youth Livestock Camp 7 ����������� Peony Fundraiser 8-9 ����� Junior Jamboree Registration Forms 10-11��� Cloverbud Day Camp Registration Forms #1 DAD

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Cooperative Extension Service l Tanana District Office l P.O. Box 758155 l Fairbanks, Alaska 99775-8155 l 907-474-1530

Tanana District 4-H News

Published by the University of Alaska Fairbanks Cooperative Extension Service in cooperation with the United States Department of Agriculture. UA is an AA/EO employer and educational institution and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination.

June 2018

Editor: Marla Lowder, 4-H & Youth Development Agent, [email protected] & Design: Ronda L. Boswell, 4-H Administrative Assistant, [email protected]

4-H:

You

r firs

t cla

ss at

UAF

!

I want to take a moment and say thank you to all for your patience with my crazy schedule and such over the past few months. Sometimes, I don’t know if I am coming or going. It seems like I get caught up at one job and then get behind in the other and then

vice versa. Then with my travel schedule added into that and the state horse contest prep, it has taken a lot of time. So, I really do appreciate your patience and support through this. So, the big things coming up are all the camps and clinics and shows. You can find more information inside the newsletter. I have sat and pondered over the past couple months on plans and such for how we can build our program back up. We have a great program and you all are great. I would just like to add to it. How do we get more leaders and ones with a variety of different projects? Then, how do we get more members? I feel the leaders we have are taxed already for the most part and feel we need more of them before we can get the youth in those project areas. I am looking for any thoughts and maybe people to help go out and reach the new or next generation. Thoughts from you are appreciated. I hope you all enjoyed this past spring. Have a wonderful June.

Marla’s Roundup •••••• June ••••••

•••••• July •••••••

1 ����������� Camp Counselor Applications Due for Cloverbud Camp

4 ����������� Teen Club meeting, 6 p.m.5 ����������� Livestock Council meeting,

6:30 p.m.8-10 ��� Livestock Clinic and Jackpot

Show9 ����������� Horse Council meeting, 10 a.m.12 �������� Leaders Council meeting,

6:30 p.m.14 �������� Junior Jamboree Camp

Counselor Training, 5:30 p.m.14-16���Equine Clinic and Schooling

Show15 �������� Registration Deadline for Junior Jamboree Camp17 �������� Father’s Day18 �������� Teen Club meeting, 6 p.m.25-28���Junior Jamboree Camp

••••••••••• What’s Inside •••••••••••2 ����������� Teen Club meeting, 6 p.m.3 ����������� Livestock Council meeting,

6:30 p.m.4-5 ����� Independence Day Holiday

(4-H office closed)9 ����������� Registration Deadline for

Cloverbud Day Camp10 �������� Leaders Council meeting, 6:30 p.m.11-13���Alaska Youth Livestock Camp

and McCullough Fitting Clinic 14 �������� Horse Council meeting, 10 a.m.16-18���Cloverbud Day Camp31 �������� Sewing Challenge, noon

2 ����������� Leaders and Members — Have You Enrolled Yet?2 ����������� Ready, Set ... Let’s Camp!2 ����������� Equine Clinic and Schooling Show Set3 ����������� Get Ready for the Fair!4 ����������� Livestock Clinic and Jackpot Show — Schedule Set5 ����������� Market Livestock Update — Important Dates6 ����������� Alaska Youth Livestock Camp7 ����������� Peony Fundraiser8-9 ����� Junior Jamboree Registration Forms10-11���Cloverbud Day Camp Registration Forms

#1 DAD

2

June 2018 Tanana District 4-H News

If you haven’t completed your enrollment online yet, you need to get it done right away. If not and something happens to you, you are not covered by insurance or liability insurance. You also should not be doing any fundraising using the 4-H name or logo. If you have questions, call the office at 474-1530 or stop in for help at 1000 University Ave., Room 109. And remember, DO NOT start a new record if you are RE-enrolling; simply sign in to your existing record and update your information from there. After completing the enrollment online, your next and final step is to pay the dues (except for leaders). Thank you!

Camp Dates Set Summer is here and we want everyone to be aware of our camp dates for this year so you can get them in your calendars. Junior Jamboree is set for June 25-28 and it always promises to be a good time! The teens have started the planning for it and the theme is set. It will be “Full STEAM Ahead.” There are some great educational classes picked out and I can’t wait! Cloverbud Day Camp is not far behind on July 16-18. We haven’t started planning this one yet, but we soon will. I know it will be a fun and exciting camp as it always is. So, if you have youth who want to attend one of these camps, watch the upcoming newsletters as things start to unfold.

READY, SET ... LET’S CAMP!Come to Junior Jamboree or Cloverbud Day Camp!

ATTENTION, LEADERS AND MEMBERS!Have you enrolled yet? If not, you need to get it done!

Find CAMP INFO & REGISTRATION MATERIALS on pages 8-11!

Equine Clinic & Schooling Show June 14-16, 2018

For more information, contact your leaders or

Anna-Marie Benson at 590-2318 or [email protected].

3

June 2018 Tanana District 4-H News

There are many fun contests to enter during the fair under Division 1 4-H Club Work. And it isn’t too early to start thinking about them. Here are the contests: My Favorite Foods — Monday, July 30, at noon — Upper Totem. In this contest, 4-H members who are enrolled in a foods project can bring their favorite food to be judged. Bake Off — Wednesday, Aug. 8, at noon — Badger Hall kitchen. Kids

enrolled in a foods project enter this one where they prepare a baked item (depends on age) in front of a judge — from start to finish. Grand champion receives a $20 fair premium. All lot champions receive a $10 fair premium. Fashion Revue and My Favorite Outfit — Sunday, Aug. 5, at 12:30 p.m. — The Big Top Tent. Here are two chances to model your outfits. Fashion Revue is for those enrolled in a sewing project who have made a garment. My Favorite Outfit is for any 4-H member who has a favorite outfit they would like to model (can be self made, store bought, made by someone else, etc.). Performing Arts and Presentations — Sunday, Aug. 5, starting right after the Fashion Revue — The Big Top Tent. This contest is for anyone who would like to do a public presentation, demonstration or performance (singing, dancing, poetry recital, playing an instrument, etc.) This can be an individual or team presentation or performance. Home Garden Tour — Tuesday, July 31, starting at 4 p.m. This is where the judge comes to your garden, which can be a flower or vegetable garden. You will be notified when the judge will be at your garden. Sewing Challenge — Tuesday, July 31, at noon — University Park Building, Room 154. Think you can sew? Come show a judge! Depending on age and level in a sewing project, contestants will do identification of machine and hand tools, and demonstrate techniques and skills by completing a selected project. Be sure to ask your leader for the Sewing Challenge guidelines. For more information on any of the contests, contact Patsy Perkins at [email protected] or 712-4544 days or 479-4529 evenings.

IT’S ALMOST FAIR TIME! Time to Get Your Contest Entries Ready!

All leaders are invited to the Lead-

ers Council meetings held the second

Tuesday of each month at 6:30 p.m.

in Room 154 at the UAF University

Park Building.

LEADERS

COUNCIL

MONTHLY

MEETINGS!

Hope to see you there!

Be sure to “LIKE” Tanana District 4-H and

Alaska 4-H on Facebook. You’ll find some

AWESOME information on these pages!

HEY, 4-H’ERS!

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June 2018 Tanana District 4-H News

Educational Opportunity for Youth Livestock Exhibitors!

Practice Showmanship & Have YOUR Market Project Animals EVALUATED! For Each Species: Showmanship Education Class, Showmanship, & Prospect Show! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Official Jackpot Judge: Marjorie Robson ~ Deschutes County, Redmond, Oregon 35 Years of Experience as a 4-H Leader and Livestock Judge

Previous Judge of Tanana Valley State Fair Large Livestock Shows ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Tanana Valley State Fairgrounds: June 8th 9th & 10th

Vet & Weigh-In Coordinated with Robert F. Gerlach, VMD, Alaska State Veterinarian & University of Alaska Fairbanks Veterinary Medicine Program

REQUIRED: Tanana District 4-H/FFA Animal Health Record & Proof of Livestock Vaccination

SCHEDULE: Friday, June 8th Small Livestock A Parent and/or Guardian 4pm-5pm Sign In & Vet In is REQUIRED to Stay at Jackpot 5-8pm Rabbit & Cavy if Youth is Participating with Animal(s)

Saturday, June 9th Large Livestock 8am-1:30pm Sign In, Vet & Weight In Large Livestock Jackpot is MANDATORY 10am Goats for 2018 4-H/FFA Large Market 11am Sheep Livestock Auction Participants Noon Lunch on Your Own 1pm Beef Small Livestock Jackpots are NOT Mandatory 2pm Swine for 2018 4-H/FFA Small Market

Sunday, June 10th Small Livestock Livestock Auction Participants 9-10am Sign In & Vet In

10am Market Poultry Please Bring Buckets/Bowls Noon Lunch on Your Own to Water Your Animal(s) 1-4pm Poultry Continued

For More Information Please Contact

The Tanana District 4-H/FFA Livestock Jackpot Committee

Point of Contacts: Jeff Rentzel 907-458-7008 or Priscilla Rice 907-347-3570 Messages May Be Left at the Tanana District CES/4-H Office 907-474-2450

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June 2018 Tanana District 4-H News

5

Cattle, Feeder Beef and BisonIBR-Bovine rhinotracheitis — requiredBVD-Bovine virus diarrhea — requiredPI-3-Parainfluenza 3 — requiredWart vaccine — suggestedReindeerClostridial, 7-way — requiredRespiratory, 3-way — requiredIBR, BVD, PI3— requiredSheep and GoatsCDT-clostridium perfringens type D & tetanus — suggestedSwineErysipelas — required (consistent with manufacturer's recommendations)

June 9: Large Livestock Jackpot Clinic and Show. The Livestock Council is bringing in an outside judge to do a clinic and a show at Tanana Valley State Fairgrounds. Event begins at 9 a.m.July 1: Check on any medicated feeds and all medica-tions for withdrawal dates for all market animals.July 8-16: Weigh-in Week. Beginning weights of all small animal market projects (turkeys, geese, ducks, chickens and rabbits) must be turned in to 4-H office along with full-body, close-up picture of animal, date picture taken and 4-H band number (tattoo number for rabbits).July 13: Organized weigh-in for turkeys, geese and ducks, 6-7 p.m., at Tanana Valley Fairgrounds, for those who wish to weigh their animals. Banding and photos also to be available.July 28: Entry Day, 1-6 p.m. at Largen Barn. Buyer contacts and record books due.July 30: Barn setup; potluck when work is finished, 5 p.m.

2018 MARKET LIVESTOCK UPDATEGuidelines according to the state veterinarian, Dr. Robert Gerlach

IMPORTANT TO NOTE!For each vaccine listed, be sure to note whether it is SUGGESTED or REQUIRED for your animal. If the vaccine is required, proof that it was administered must be submitted on entry day. Proof consists of the following: l Name of vaccine l Expiration date: Vaccine shall not be expired when administered. l Manufacturer l Date vaccine administered l Lot number l Who administered vaccine

Vaccinations — Suggested or Required? Things the veterinarian will look for on delivery day:

warts, enlarged external lymph nodes (especially on sheep and goats), infectious or conta-gious diseases (including external para-

sites), clinical signs of dermatitis (ringworm) and evidence of castration, when applicable.

You should have the animal in the best physical shape prior to going to the fair. This

includes providing good nutrition, vaccinations and parasite control. These precautions will en-

able the animal to have a strong immune system and avoid getting ill when they are exposed to the

other animals and the stress of being away from home and at the fair.

Important Dates to Remember!Aug. 2: Delivery of animals to fair. Small animals, 2-8 p.m., and large animals, 4-8 p.m. Remember, there will be a vet check before animals can be brought into the barns.Aug. 3: Mandatory barn meeting, 11 a.m.Aug. 3: Official fair weigh-in, noon-2 p.m.Aug. 10: Mandatory barn meeting, 11 a.m.Aug. 12: Animal pickup day and barn cleanup, 7 a.m.Aug. 26: Small animals delivered to buyer unless other arrangements with buyer are made.Sept. 10: Record books turned in to 4-H leader/FFA advi-sor in order to be eligible for a market project next year.

Questions? Contact Marla Lowder at 474-2427 or [email protected].

* REMEMBER TO DO YOUR SHOWMANSHIP CLINICS! WATCH LISTSERV FOR DATES!

6

June 2018 Tanana District 4-H News

Alaska Youth Livestock Camp

McCullough Fitting Clinic

Maine Aim Ranch- Teaching all you need to know to Clip, Fit and

Join us on: JULY 11-13, 2018Location: ALASKA STATE FAIR GROUNDS, PALMER, ALASKA

Event Schedule: Presenters

Wednesday, July 11, Beef

Thursday, July 12, Beef

Sheep/Goats

Friday, July 13, Beef

Sheep/Goats

Showmanship Contest/Awards/Closing

Registration Fees: Limited Youth Enrollment for each species.

Mat-Su/Copper River Enrolled in 4

Non-Enrolled 4-H & Other District 4

Contact for Registration & Questions

Erin Sturdivant, 907

Alaska Youth Livestock Camp

McCullough Fitting Clinic

Teaching all you need to know to Clip, Fit and Show like a PRO!

13, 2018 ALASKA STATE FAIR GROUNDS, PALMER, ALASKA

Presenters - Chuck & Karen McCullough & Family

Beef - Washing, Everyday Care, Feeding

Beef - Blades and Clippers, Clipping

Sheep/Goats – Washing, Everyday Care, Feeding

Beef - Fitting, Showmanship

Sheep/Goats – Clipping, Fitting, Showmanship

Showmanship Contest/Awards/Closing

Limited Youth Enrollment for each species.

Su/Copper River Enrolled in 4-H - $25 fee

Other District 4-H Youth - $50

Contact for Registration & Questions

Erin Sturdivant, 907-315-8122 [email protected]

Alaska Youth Livestock Camp

Teaching all you need to know to Clip, Fit and

[email protected]

7

June 2018 Tanana District 4-H News

7

8

June 2018 Tanana District 4-H News

8

Junior Jamboree is an overnight camp designed for youth who are going into grades 4, 5, 6, 7 and 8. Camp will run June 25-28 at Twin Bears Camp, which is located on Chena Hot Springs Road between Mile 29 and 30. Youth will rotate through classes based on the theme “Full STEAM Ahead!” Swimming, crafts, group games, campfire ceremonies, skits and singing will still be a part of the traditional

camp fun! Campers will belong to a cabin group headed by a high school-aged 4-H counselor. Adult 4-H leaders and the 4-H agent will serve as chaperones, directors and volunteer leaders of activities.

Camper’s Name: Gender:________ Grade Completed:_________

Mailing Address: _____ City: Zip:____________

Parent’s Name: ________________________________________ Home Phone: _________ Work Phone:________

Email:__________________________________________________________________________________________

Are you currently enrolled as a 4-H member? Yes No

Check fee enclosed: _____$95 4-H member _____$85 additional family 4-H members _____$110 Non-4-H member _____$20-late fee if after June 15 TOTAL DUE: $________ (Make checks payable to Tanana District 4-H Leaders Council.)

REGISTRATION FORM — JUNIOR JAMBOREE 2018

REGISTER BY JUNE 15! ($20-late fee charged after June 15.)

ARRIVAL & DEPARTURE: l Campers arrive at 6 p.m. Monday, June 25. (Please note: Dinner will NOT be provided for campers on June 25.) l Campers leave at 11 a.m. Thurs- day, June 28.

REGISTRATION FEES: l 4-H member — $95 ($85 for addi- tional enrolled family members) l Non-4-H member — $110 l Registration deadline — June 15 l Late fee — $20 l Limit — 40 campers

Please detach, complete and return registration form by June 15. Be sure to include the Emergency & Medical/Health Information Form on next page! Mail both forms and pay-ment to: 4-H Junior Jamboree, Cooperative Extension Service, P.O. Box 758155, Fairbanks, AK 99775-8155. For questions, call 474-1530 or 474-2427.

PLEASE PRINT CLEARLY! Thank you!

Full STEAM Ahead!YOUTH/4-H JUNIOR JAMBOREE

June 25-28, 2018 @ Twin Bears Camp

Science Technology Engineering Arts Mathematics

Published by the University of Alaska Fairbanks Cooperative Extension Service in cooperation with the United States Department of Agriculture. UA is an AA/EO employer and educational institution and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination.

9

June 2018 Tanana District 4-H News

Leaders should keep a copy of this form to have available when they are with club members.

Form date: 11-17

Emergency & Medical / Health Information

Name _________________________________________ Birth date ________ Sex _________ Age _________ Parent or guardian ________________________________________ Email ________________________________ Mailing address __________________________________________________________________________________ Physical address _________________________________________________________________________________ Home phone ____________________ Work phone _____________________ Cell phone ___________________

Relatives or friends to act in my behalf, in case of emergency, if I cannot be reached: _________________________________________ __________________________________________________ Emergency contact name/relationship Emergency contact name/relationship __________________ ____________________ _______________________ ________________________ Home phone Alternate phone Home phone Alternate phone _________________________________________ __________________________________________________ Address Address

Family physician ________________________________________ Phone ________________________________

Under doctor’s care now? ___________ If yes, please explain on back. Prescribed medicine ____________________________________________ (All meds must be turned in to chaperone or camp nurse.) Allergies to medications/foods/insects/other? ________ List ____________________________________________

Health History: Is youth subject to: Indicate YES or NO _____ Hernia _____ Hay fever ______ Nervous disorders ______ Asthma _____ Frequent colds _____ Fainting spells ______ Sleepwalking ______ Ear/sinus _____ Allergies _____ Insect stings ______ Drug sensitivity ______ Enuresis (bed wetting) _____ Epilepsy _____ Heart trouble ______ Diabetes (take insulin?) _____ Food allergies _____ Bleeding/clotting disorders

If YES on any of the above, please explain ____________________________________________________________ ______________________________________________________________________________________________ Has the youth had: _____ Poliomyelitis _____ Hay fever _____ Rheumatic fever _____ Appendicitis attack _____ Measles ______ Mumps _____ Chicken pox _____ Whooping cough ______ Scarlet fever Is the youth pregnant? ________________________ Date of last tetanus booster: ___________________________

Identify any physical/emotional problems that would prevent full participation in the program. ___________________ ______________________________________________________________________________________________ Emergency Authorization: I hereby give my permission to the medical staff selected by the Cooperative Extension Service faculty/staff to order x-rays, routine tests and treatment for the above named youth. In the event I, or one of the above named designees cannot be reached in an emergency, I hereby give my consent to emergency medical treatment, hospitalization or other medical treatment as needed. I will assume all financial obligations incurred if not covered by insurance.

___________________________________________________ ___________________________________ Signature of parent/guardian Date

Note: If bringing medications to the event or program, please make sure that your name is on them and that dosage directions are clearly indicated.

10

June 2018 Tanana District 4-H News

This day camp offers an adventure in the out-of-doors for children who are just completing grades K, 1 and 2. It provides the fun of camp with the security of evenings at home. The program runs July 16-18, 9 a.m.-1 p.m., at the Georgeson Botanical Garden, located on UAF Campus. Nature observations, crafts, games and educational adventures are designed to the in-

terest and attention span of this age group. FUN is the key ingredient! Staff will include the 4-H agent, volunteer junior teens, adult leaders and resource people from the community.

CLOVERBUD DAY CAMPJuly 16-18, 2018

UAF Georgeson Botanical Garden

INFORMATION: l Tanana District Extension Office 474-1530 or 474-2427

WHAT TO BRING: l Sack lunch (beverages and snacks provided) l Jacket l Rain boots

DROP OFF/PICK UP: l Day camp begins at 9 a.m. l Pick up is at 1 p.m.

REGISTER BY JULY 9! ($15-late fee applied after July 9.)

Camper’s Name: Gender:________ Grade Completed:__________

Mailing Address: _____ City: Zip:____________

Parent’s Name: ________________________________________ Home Phone: _________ Work Phone:________

Email:___________________________________________________________________________________________

Are you currently enrolled as a 4-H member? Yes No

Check fee enclosed: _____$35 4-H member _____$40 Non-4-H member _____$15-late fee applied after July 9 TOTAL DUE: $________ (Make checks payable to Tanana District 4-H Leaders Council.)

REGISTRATION FORM — CLOVERBUD DAY CAMP

PLEASE PRINT CLEARLY! Thank you!

Weee!

REGISTRATION FEES: l 4-H member — $35 l Non-4-H member — $40 l Registration deadline — July 9 l Late fee — $15

l Limit — 25 day campers

Published by the University of Alaska Fairbanks Cooperative Extension Service in cooperation with the United States Department of Agriculture. UA is an AA/EO employer and educational institution and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination.

Please complete, detach and return registration form by July 9. Be sure to include the Emer-gency & Medical/Health Information Form on next page! Mail both forms and payment to: 4-H Cloverbud Day Camp, UAF Cooperative Extension Service, P.O. Box 758155, Fairbanks, AK 99775-8155. For questions, call 474-1530 or 474-2427.

11

June 2018 Tanana District 4-H News

Leaders should keep a copy of this form to have available when they are with club members.

Form date: 11-17

Emergency & Medical / Health Information

Name _________________________________________ Birth date ________ Sex _________ Age _________ Parent or guardian ________________________________________ Email ________________________________ Mailing address __________________________________________________________________________________ Physical address _________________________________________________________________________________ Home phone ____________________ Work phone _____________________ Cell phone ___________________

Relatives or friends to act in my behalf, in case of emergency, if I cannot be reached: _________________________________________ __________________________________________________ Emergency contact name/relationship Emergency contact name/relationship __________________ ____________________ _______________________ ________________________ Home phone Alternate phone Home phone Alternate phone _________________________________________ __________________________________________________ Address Address

Family physician ________________________________________ Phone ________________________________

Under doctor’s care now? ___________ If yes, please explain on back. Prescribed medicine ____________________________________________ (All meds must be turned in to chaperone or camp nurse.) Allergies to medications/foods/insects/other? ________ List ____________________________________________

Health History: Is youth subject to: Indicate YES or NO _____ Hernia _____ Hay fever ______ Nervous disorders ______ Asthma _____ Frequent colds _____ Fainting spells ______ Sleepwalking ______ Ear/sinus _____ Allergies _____ Insect stings ______ Drug sensitivity ______ Enuresis (bed wetting) _____ Epilepsy _____ Heart trouble ______ Diabetes (take insulin?) _____ Food allergies _____ Bleeding/clotting disorders

If YES on any of the above, please explain ____________________________________________________________ ______________________________________________________________________________________________ Has the youth had: _____ Poliomyelitis _____ Hay fever _____ Rheumatic fever _____ Appendicitis attack _____ Measles ______ Mumps _____ Chicken pox _____ Whooping cough ______ Scarlet fever Is the youth pregnant? ________________________ Date of last tetanus booster: ___________________________

Identify any physical/emotional problems that would prevent full participation in the program. ___________________ ______________________________________________________________________________________________ Emergency Authorization: I hereby give my permission to the medical staff selected by the Cooperative Extension Service faculty/staff to order x-rays, routine tests and treatment for the above named youth. In the event I, or one of the above named designees cannot be reached in an emergency, I hereby give my consent to emergency medical treatment, hospitalization or other medical treatment as needed. I will assume all financial obligations incurred if not covered by insurance.

___________________________________________________ ___________________________________ Signature of parent/guardian Date

Note: If bringing medications to the event or program, please make sure that your name is on them and that dosage directions are clearly indicated.