thank you so much for your interest in attending...
TRANSCRIPT
Thank you so much for your interest in attending 4-H Camp! We are excited for
another great week this summer and are looking forward to you joining us!
Some great changes have taken place since last summer including air conditioning
in the cabins and in the dining hall as well as some new staff led classes!
Who Can Attend Camp: All youth who have graduated 3rd grade are eligible to
attend 4-H Camp in the summer of 2018.
Where: North Central 4-H Camp
260 St-1035, Carlisle, KY 40311
Cost: Camp cost is $235 which covers all transportation to and from camp, all
meals and snacks, all class fees and a t-shirt. Limited half scholarships are
available on a need basis by application.
NEW THIS YEAR - Help a 4-H Youth Attend Camp! Families with the ability are
invited to contribute to the 4-H Camp Scholarship General Fund by paying over
the minimum $235. Any additional money would go towards offering camp
scholarships for those who apply.
When: Monday, July 16th - Friday, July 20th, 2018
We will be hosting a mandatory camper orientation on Thursday, June 28th at
6:00pm at the Woodford County Extension Office. During this time we will go
over camp rules, packing information, schedule and cabin assignments.
Deadline: Camp applications are due no later that June 1st, 2018 and spots are
filled on a first come, first served basis.
This year we are offering a unique camping experience for male campers. Staying at Outpost
offers a more traditional camping experience where campers spend their week in an open-air
shelter rather than a cabin and enjoy a more rustic experience including making campfires at
night. If you would be interested in staying at Outpost, please check the box below.
Outpost (Males only)
Campers staying in the Outpost will still participate in all camp activities including classes and
will still be chaperoned by adult and junior counselors according to camp policies.
Beginning Swimming
Advanced Swimming
Archery
Riflery
Nature
Recreation
Outdoor Living
Canoeing
Low Ropes
High Ropes
Kayaking
Ultimate Frisbee
Soccer
Photography
Gaga Ball
Leadership
Fishing
Basketball
Volleyball
Foods
Crafts
Received by: __________________ Date: ________________________
Cabin Assignments
What makes 4-H Camp the best is that you get to enjoy it with all of your friends!
In the space below, please indicate two other campers that you would like to bunk
with in the same cabin. We’ll use these names to fill classes as well. While cabin
and class spots are limited and we can’t make any guarantees, we will do our best
to place everyone with their friends!
______________________________ ______________________________
Class Sign-ups
Classes at camp are a great opportunity to learn a new skill or try something new!
Each camper takes four classes that each last an hour, and they take the same four
classes on Tuesday, Wednesday and Thursday. We are doing class sign-ups prior to
heading to camp, which will free up even more time for great activities once we
get there! Below is a list of classes we are offering this summer at 4-H Camp.
Please rank each class 1-21, with #1 being your absolute favorite class and #21
being the class you want to take the least. Please refer to the next page for class
descriptions!
Classes are filled on a first-come, first-served basis and spots are divided evenly
among the three counties. Keep in mind that while not everyone is guaranteed their
four favorite classes, we will do our best to make sure you end up in as many
top-ranked classes that you like!
Class Descriptions
Advanced Swimming – Par ticipate in water activities/games; Use diving board
Archery – Learn archery safety and basic skills; Use archery equipment at range
Basketball – Learn basic skills and par ticipate in games
Beginning Swimming – Learn basic swim techniques; Par ticipate in water activities/games
Canoeing – Learn canoeing safety, basic skills, and water games; Use canoes on lake
Crafts – Make var ious crafts dur ing the week
Fishing – Learn fishing safety and basic skills; Fish at the lake
Foods – Learn basic food preparation skills and create your own snack foods
Gaga Ball – Learn basic skills and par ticipate in games (The game is played within a r ing with
short panels, and uses a playground ball that is bounced so that players attempt to tag another player in
the lower leg with the ball in order to get them out)
High Ropes – Learn rock climb wall safety and skills for climbing; Learn zipline safety; Climb
40 foot mock rock wall and zipline down on the other side
Kayaking - Learn kayaking safety, basic skills, and water games; Use kayaks on lake
Leadership – This is open to older youth that want to learn more about leadership, in prepara-
tion to being a camp counselor in the future (Counselors in Training must sign up for this class)
Low Ropes – Par ticipate in low rope elements not far from the ground, while working as a team
to complete challenges (examples: rope bridge crossing, bridge balance, rope spider web activity, and
many more)
Nature – Learn about nature as you take hikes on the trails around camp
Outdoor Living Skills – Learn how to build and cook over campfires; How to build shelters; Get an
intro to wilderness first aid
Photography – Learn basic photography skills and techniques; Take photos during camp week
Recreation – Learn and par ticipate in var ious games and camp dances
Riflery – Learn r ifle safety and basic skills; Use equipment at range
Soccer – Learn basic skills and par ticipate in soccer games
Ultimate Frisbee – Learn basic skills and par ticipate in games (The game uses a Fr isbee that is
passed from team members using only a few steps at a time in an effort to get the Frisbee over the
goal line)
Volleyball – Learn basic skills and par ticipate in games
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 Physician
Name: Address:
Phone
Medical and Dietary Restrictions (list all known and reaction management):
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 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? YES (Attach a copy – front and back – of the insurance card in the boxes below.)
NO (No worries! Camp provides an excess medical insurance coverage in the event of injuries or illnesses.)
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
CAMP USE ONLY (Healthcare Staff Review Stamp)
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 in the Kentucky 4-H Summer Camping Program is based on the challenge by choice philosophy. I
recognize that programs are designed to use experiential, engaging teaching techniques, but that my child’s participation is purely voluntary, always,
and my child will choose his or her level of participation in any activity. The camp activities listed below require acknowledgement of the risks
involved and permission to participant from the parent/guardian. Place a check indicating YES or NO next to each 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 to this policy regardless of
relationship to the child. Please inform everyone approved by you on this release that he/she must present a driver’s license or photo ID before the
child will be released. Parents, Guardians, and Emergency Contacts listed on page 1 are automatically assumed to have pick up
authorization. In addition to the parents/guardians listed on page 1, the following individuals are granted permission to pick up my child
NAME: __________________________ RELATIONSHIP________________________________ Phone/Cell# ______________________
NAME: __________________________ RELATIONSHIP________________________________ Phone/Cell# ______________________
NAME: __________________________ RELATIONSHIP________________________________ Phone/Cell# ______________________
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: _______________________