February 1, 2020

2020 Summer 4-H Camp Teen Counselors:

Summer 4-H Camp June 1-5, 2020

North Central 4-H Camp, Carlisle, KY

Junior Counselors in Training (JCIT): 14-15 years old

(As of June 1, 2020)

Junior Counselors (JC): 16-18 years old (18 year old in High School)

(As of June 1, 2020)

Being a 4-H Camp Counselor is a great way to build leadership skills, by motivating campers in

group games, helping campers adjust to group living, leading camp songs, teaching workshops,

making new friends and learning life skills that will help you build your resume and grow as an

individual. Did we mention you get community service hours?

Mark your calendar with the following dates:

Application Deadline: Monday, March 16, 2020 (by 4:00pm)

Junior Counselor (JCIT & JC)Interviews: Week of April 13-15 at GRC/Extension Office

Camper Orientation: Tuesday, May 19 Registration will begin at 9:30 AM and orientation will start at 10 AM at the Clark County Fairgrounds, Shelton Building.

All Counselor Orientation: Saturday, May 23, 2020 at North Central 4-H Camp

Camp: June 1-5, 2020

You can make a difference in a camper’s experience at 4-H Summer Camp! Without you camp

would not be possible! Please contact the Clark County Extension Office for application

packets and with questions at (859) 744-4682 or email Shannon.farrell@uky.edu.

Sincerely, Shannon Farrell Clark County Agent for 4-H Youth Development

Cooperative Extension Service

Clark County

1400 Fortune Dr

Winchester, KY 40391

859-744-4682

Fax: 859-744-4698

http://extension.ca.uky.edu

Kentucky 4-H Camping 2020

Camp Participant Registration – Camper/Teen

Last Name: Legal First Name: Middle Name: Preferred Name:

Attended camp before?

❑ Yes - # years: ___

❑ No

Fall 2020 School & Grade: County: Gender Identity:

❑ Male

❑ Female

Shirt Size: (Select One)

YS YM YL YXL AS AM AL AXL A2XL A3XL A4XL

Birthdate:

______ / ______ / ______

Age on 1st day of camp?

Participant’s Home Address: Participant’s Race:

❑ White

❑ Black

❑ Asian

❑ American Indian

❑ Hawaiian

❑ Other

Participant’s Ethnicity:

❑ Hispanic

❑ Non-Hispanic

Legal Parent/Guardian #1 Full Name: Email Address: Cell/Home Number:

Legal Parent/Guardian #2 Full Name: Email Address: Cell/Home Number:

Emergency Contact Full Name: Relationship to Participant: Cell/Home Number:

Physician Name: Physician Phone Number:

Buy your participant some camp gear. www.4hcampstore.com

Is your participant looking for more camp opportunities? www.4hcampevents.com

What is specific information about your camp participant which the staff should be made aware of to provide a better camp experience

for the camp participant? Are there specific items that the participant is provided at home or school to have a successful experience?

Behavioral (i.e., mental, emotional, physical)

Medical (i.e., asthma, autism, sleepwalker, braces, glasses)

Dietary (i.e., gluten intolerant, sensitive to dairy, picky eater)

Other accommodations or important details:

Is the camp participant up to date on immunizations as outlined by Kentucky law required for enrollment in public, private, or home

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. Use tape, DO NOT staple.)

❑ NO (No worries! The camp provides excess medical insurance coverage in the event of injuries or illnesses.)

FRONT OF INSURANCE CARD BACK OF INSURANCE CARD

PARTICIPANT NAME: ____________________________________________________

PARTICIPANT NAME: _______________________________________________________________________________

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

MEDIA RELEASE:

I grant the Kentucky 4-H Program and the University of Kentucky, Kentucky State University, 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.

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 and 2 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# ______________________

CONSENT TO TREAT:

The health history reported on page one and two are correct and complete to the best of my knowledge. 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 off camp property.

CODE OF CONDUCT:

I have read and discussed the Camp Code of Conduct with my participant. We (parent/guardian and participant) understand and agree to comply with

the guidelines. Violations may result in loss of privileges, removal from camp with no refund, assessment of a damage fee for which 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.

ASSUMPTION OF RISK, RELEASE OF LIABILITY, and PERMISSION TO PARTICIPATE:

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, Kentucky State University, 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. 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 (including, but not limited to: high ropes, rock climbing, low challenge elements,

rifles, archery, trap shooting, horses, and cave exploration).

Participant Signature: ____________________________________________________ Date: _______________________

Parent/Guardian Signature: ____________________________________________________ Date: _______________________

2020 Application

4-H SUMMER CAMP COUNSELOR

(APPLICATION DUE: Monday, March 16, 2020 by 4:00pm)

Applying for: COUNSELOR-IN-TRAINING (JCIT) (Check one) (14 or 15 years of age as of June 1, 2020)

JUNIOR COUNSELOR (JC) (16-18 years old as of June 1, 2020) 18 if still in high school

Name:

Age: (as of June 1, 2020) Gender (circle one): M F

Address:

Zip:

Email:

Counselor Phone: ( ) _________ Date of Birth: __ / __ / __

Parent/Guardian Name(s): Phone:

School: ___________________________ Current Grade:

Have you ever attended 4-H Camp? (circle) Yes No How Many Years: __

Have you ever been a camp counselor before? (circle) Yes No How Many Years: _ _

List any previous responsibilities as a counselor: ______

_________________________________

_________________________________

List previous and current 4-H and School events and activities you have been involved with: _________________________________

_________________________________

_________________________________

List previous and current school activities/clubs you have been involved with: _________________________________

_________________________________

2020 Application

4-H SUMMER CAMP COUNSELOR

Do you hold any current certifications in CPR, Lifeguarding, etc.?: (List):

_________________________________

Describe any experiences you have working with younger children: ____

_________________________________

_________________________________

Why do you want to be a 4-H camp counselor?: _____ _____________

_________________________________

_________________________________

What qualities do you have that would make you a good camp counselor: __ ____

_________________________________

Please have references complete and sign attached recommendation forms place in sealed envelope, return by mail to Extension Office, hand deliver or scan and email to Shannon.farrell@uky.edu. Reference should not be parent/guardian or related to the applicant. All forms must be turned in by March 16, 2020 by 4:00pm. List names and phone number of references below:

1) ___________________________________________________________

2) ___________________________________________________________

I understand that my attendance at each of the following events in addition to camp is mandatory to participate in 4-H Summer Camp as a Camp Counselor. By initialing each line below I understand that I must be present at each event to be eligible to attend 4-H Summer Camp as a Junior Counselor in Training or a Junior Counselor. Failure to attend one or all of these events may result in being removed from the 4-H Summer Camping Program as a Camp Counselor.

______ Week of April 13-15 at GRC/Extension Office (All Counselors are required to Interview)

______ Tuesday, May 19 (Camper Orientation) Registration will begin at 9:30 AM and orientation will start at 10 AM at the Clark County Fairgrounds, Shelton Building.

______ Saturday, May 23 (All Counselor Training) at North Central 4-H Camp

If I am selected as a 4-H Summer Camp Counselor I understand that the following materials must be turned in by Tuesday, May 19th. SIGNATURE OF APPLICANT: ___________________________________________ Date:_________________

______ New Counselor Training Modules (Will be mailed to address on application if you are selected as a counselor.)

SIGNATURE OF PARENT/GUARDIAN: ___________________________________ Date:_________________

4-H CAMPCOUNSELOR

VOLUNTEER POSITION DESCRIPTION: Kentucky 4-H Youth Development Program Kentucky Cooperative Extension The University of Kentucky College of Agriculture, Food and Environment

POSITION TITLE: 2020 4-H Summer Camp Junior Counselor

TIME REQUIRED / DURATION OF APPOINTMENT -Must read and complete orientation materials

-Complete all application materials and have references completed by March 16, 2020 by 4:00pm

-All Counselors must interview on week of April 13-15, 2020

-Attend Camper Orientation, Tuesday, May 19, 2020 (Registration will begin at 9:30 AM)-Attend All Counselor Orientation, Saturday, May 23, 2020

-Five Days and Four Nights of Camp (Monday-Friday), June 1-5, 2020

LOCATION:

JC/CIT Orientation: North Central 4-H Camp near Carlisle, KYCamper Orientation: at the Clark County Fairgrounds, Shelton BuildingCamp: North Central 4-H Camp near Carlisle, KY

GENERAL PURPOSE:

Help supervise 12-16 youth, ages 9-13, in a camping setting

Support 4-H professionals, volunteers and members in conducting meaningful educational experiences to help youth develop social skills.

SPECIFIC RESPONSIBILITIES: Be committed to the development of young people

Provide leadership and direction while working closely with adult counselors and agents

Involve campers in all scheduled activities while at camp

Make sure campers are on time for programs

Under the direction of the adult counselor in your cabin, supervise group living environment (i.e. housekeeping, personal hygiene, social skills, responsibility, sharing, following rules, discipline campers)

See that campers carry out responsibilities such as cabin cleanup, grounds cleanup, dining hall cleanup, etc.

Participation in all camp activities including swimming

Counsel homesick campers

Be responsible for the health, safety and happiness of each camper in their cabin

Participate in implementing the camp’s program

Report any problems to your adult counselor, Dean of Men/Women, or County Agent

Assist class instructors where needed in teaching or in managing campers’ behavior

Assist adult counselors, permanent staff and agents, upon request, with special

activities such as quiet time, flag raising/lowering, etc.

A willingness to become familiar and work with the philosophy, guidelines and rules of the University of Kentucky CES, Kentucky 4-H Youth Development Program and the county 4-H program

QUALIFICATIONS: Must complete all Clark County 4-H Summer Camp Counselor Application

forms and go through interview process

Self-starter; be able to work with minimal supervision from professional staff.

Effective communication skills.

A sincere interest in working with extension staff, volunteers, parents, and youth.

Organizational skills; ability to organize information and materials in a timely manner.

MUST BE 14 YEARS OR OLDER BY JUNE 1, 2020.

Ability to get along with others

Willingness to follow rules

I understand the position description as given to me by the Clark County 4-H Youth Development Agents. I also understand my role as Junior Counselor during the week of 4-H Summer Camp.

Junior Counselor Signature Date

Supervising Agents Signatures Date

Please sign and return with JC Application to: Shannon Farrell

Due by March 16, 2020 by 4:00 pm! 4-H Youth Development AgentClark County Extension Office 1400 Fortune Drive Winchester, KY 40391

(859) 744-4682shannon.farrell@uky.edu

OFFICE USE ONLY: DATE RECEIVED:

Clark County 4-H Counselor Recommendation Form Teen Leaders for 4-H Summer Camp 2020

Please complete the following form, place in a sealed envelope. Recommender may choose to mail to the Clark County Extension Office (1400 Fortune Drive, Winchester, KY 40391), return to

applicant in secured envelope or scan/email to: shannon.farrell@uky.edu. Please remember recommender should not be parent/guardian or related to applicant.

All reference forms are due by Monday, March 16th, 2020 at 4:00pm.

Name of Person Completing Reference Form: ______________________

Name of Person Reference is for: _________________________

Relationship to Applicant: ______________________

How many years have you known applicant? _________

Please rank the applicant in the following areas based on your first-hand knowledge of him/her: Strong Adequate Weak Not Observed Specific Comments

Emotional Maturity Physical Stamina Enthusiasm Team Player Leadership Skills Stress Management Decision Making & Problem Solving Skills Ability to Handle Conflict Interaction/Connection with children Interaction/Connection with adults Interaction with Supervisors/Authority Figures

What would you consider to be the applicant’s greatest strengths?

If you could encourage the applicant to grown in any way, what would it be and why?

-continued on reverse-

2

Please mark the words below that best describe the applicant (choose all that apply):

__Team Player __Organized __Responsible __Critical __Punctual

__Role Model __Flexible __Honest __Confident __Approachable

__Productive __Bossy __Creative __Safety-Minded __Helpful

__Loyal __Easy Going __Unpredictable __Athletic __Positive

__Dependable __Arrogant __Influential __Enthusiastic __Judgmental

__Cooperative __Outgoing __Untidy __Prepared __Respectful

If your opinion, is the applicant able to cope with potential challenges that come with working with children? _____yes _____no If no, please comment:

Please provide any additional information that you feel would help in our decision making process as we choose our volunteer team for 4-H Summer Camp 2020.

Would you recommend this applicant as a Teen Leader for 4-H Summer Camp 2020?

_____yes _____yes, with some reservations _____no

Signature of Reference: ___________________________Date: _____________

Email address: ______________________________Phone: _______________

Clark County 4-H Counselor Recommendation Form Teen Leaders for 4-H Summer Camp 2020

Please complete the following form, place in a sealed envelope. Recommender may choose to mail to the Clark County Extension Office (1400 Fortune Drive, Winchester, KY 40391), return to

applicant in secured envelope or scan/email to: shannon.farrell@uky.edu. Please remember recommender should not be parent/guardian or related to applicant.

All reference forms are due by Monday, March 16th, 2020 at 4:00pm. Name of Person Completing Reference Form: ______________________ Name of Person Reference is for: _________________________ Relationship to Applicant: ______________________

How many years have you known applicant? _________ Please rank the applicant in the following areas based on your first-hand knowledge of him/her: Strong Adequate Weak Not Observed Specific Comments Emotional Maturity Physical Stamina Enthusiasm Team Player Leadership Skills Stress Management Decision Making & Problem Solving Skills

Ability to Handle Conflict

Interaction/Connection with children

Interaction/Connection with adults

Interaction with Supervisors/Authority Figures

What would you consider to be the applicant’s greatest strengths? If you could encourage the applicant to grown in any way, what would it be and why?

-continued on reverse-

2

Please mark the words below that best describe the applicant (choose all that apply): __Team Player __Organized __Responsible __Critical __Punctual

__Role Model __Flexible __Honest __Confident __Approachable

__Productive __Bossy __Creative __Safety-Minded __Helpful

__Loyal __Easy Going __Unpredictable __Athletic __Positive

__Dependable __Arrogant __Influential __Enthusiastic __Judgmental

__Cooperative __Outgoing __Untidy __Prepared __Respectful If your opinion, is the applicant able to cope with potential challenges that come with working with children? _____yes _____no If no, please comment: Please provide any additional information that you feel would help in our decision making process as we choose our volunteer team for 4-H Summer Camp 2020.

Would you recommend this applicant as a Teen Leader for 4-H Summer Camp 2020? _____yes _____yes, with some reservations _____no Signature of Reference: ___________________________Date: _____________ Email address: ______________________________Phone: _______________

Kentucky 4-H Camping Code of Conduct and Expectations

1. Campers are not permitted to bring cell phones to camp2. Possession or use of alcohol, illegal drugs, or weapons by any person is prohibited.3. Use of tobacco products is not allowed for campers/teens at 4-H camp. Should a county(s)

decide to permit adults (18 years and over) to use them, it may occur only in areasdesignated by the Camp Director. Absolutely no tobacco products in cabins, woods orother areas of camp.

4. Boys and girls cabin areas are restricted. A camper of the opposite gender is not, at anytime, to enter a restricted area.

5. Campers are not allowed in the cabins during a class or activity. If a camper is ill, he/sheis to stay at the medical center (not in a cabin) until the Health Care Provider (HCP) feelsthe camper may return to activities.

6. Campers are to be attentive, responsive and courteous to any staff, adult or teen counselormaking a presentation before the group.

7. Absolutely no phone calls are to be made by campers (camp phone or cell phone) withoutapproval of the County Extension Agent. All County Extension Agents should be informedof incoming calls to campers.

8. Accidents or illnesses, no matter how minor, are to be reported to the Healthcare Providerand County Agent.

9. Obscene, discriminatory and/or inappropriate language or dress, roughhousing, andinsubordination is not acceptable at any time during camp.

10. Fireworks are not to be used by campers at any time during camp.11. Swimming, boating, or any waterfront activity is not permitted except during designated

times and under proper supervision.12. Appropriate dress, including footwear, should be adhered to as outlined at camper

orientation.13. Campers are always to remain with their groups, and must obey the rule of 3 when

traveling. Individuals are not to be on the trails or near the lakes without an accompanyingadult.

14. Campers are not permitted to leave the grounds at any time without notifying andreceiving approval from the Camp Program Director and their County Extension Agent.

15. All campers are expected to be in their cabins, with lights out, as designated on the campprogram.

16. No visitors, other than parents or immediate family, may visit campers during the camp.17. No camper is to be around or on maintenance equipment.18. Campers who are having personal conflicts with other campers should discuss these with

their cabin counselor, dean or County Extension Agent.19. Campers are to work with counselors in carrying out daily assigned jobs to help keep the

camp running smoothly. Grounds are to be kept clean at all times. Campers are expectedto leave the cabins, facilities and grounds clean and orderly.

20. Campers are to respect camp property. Any malicious or intentional damage to campproperty or buses shall be paid for by the camper and/or parent or guardian, includinggraffiti.

21. All medications must be turned in to the designated adult and picked up by theparent/guardian at the bus pick up site. The Health Care Provider will be responsible forsecuring all medications at camp.

22. Camp is not responsible for personal property of any camper, volunteer or staff.23. We care about the safety of all camp participants, incidents of serious misbehavior (i.e.

fighting, bullying, causing injury, alcohol/drug incidents, any altercations between adultsand/or minors, intentional property damage/vandalism, etc.) will be reported to the CampDirector and County Extension Agent and an incident report will be completed.

24. Campers should demonstrate respect toward others. Bullying, hazing or malicious pranks(i.e.: shaving cream, toothpaste in pillow/sleeping bags, defacing property, includinginappropriate use of electronics/social media) will not be tolerated and may result in theperpetrator(s) being sent home.

Any conduct inconsistent with the above rules may result in consequences such as the camper/family/friend being sent home, restricting future participation in 4-H activities, termination of 4-H membership, or other consequences determined by the county’s or state’s policy. If a camper must be sent home, it will be the responsibility of the parent/guardian to pick him or her up at camp. There is no refund of the camper fee for an early departure.

Participant Signature

Parent/Guardian Signature

Date

Clark & Montgomery Camp Notification Policy

Notification of Changes Parent(s)/guardian(s) listed on the camp form will be notified of changes from the schedule as indicated

through Remind text messages and/or telephone calls. Parents will be notified (using the first number

provided on the custodial/guardian line of the campers form) of any changes in time or location on the

departure day and the arrival day. Please be sure that the number you provide us is a phone number at

which you can be reached at any time.

Injury/Illness Parents will not be notified of every bump, bruise, or minor illness. Parents will be notified when the

Health Care Professional deems it necessary and/or off-site medical treatment is needed.

Emergency Policy If an emergency situation arises that directly involves a camper, parent/guardian(s) of the camper will be

notified by one of the 4-H Agents or their designated representative at a time deemed appropriate and safe

by the agents.

Cell Phones Campers are not permitted to have cell phones while at camp. Being “at camp” includes transportation to

and from camp. Parents will not be notified when a camper has their cell phone confiscated. Phones that

are confiscated will be turned off, placed in a safe storage, and returned to the camper upon return from

camp.

Disciplinary Issues The Clark or Montgomery County 4-H Agents will be consulted on all disciplinary issues by the teen

leaders/adult leaders. Camp rules must be followed. A camper’s or teen leader’s parent/guardian will only

be notified of any flagrant violation of camp rules. A flagrant violation will result in the camper/teen

leader being sent home and must be picked up at camp by parent/guardian or someone from their pick-

up/release list.

Refusal to Pick Up Camper/Teen Leader When a parent/guardian is notified that they need to come to camp and pick up their camper/teen leader,

they must do so in a timely manner. The agents don’t make the decision to send someone home (either for

illness or discipline) unless it is absolutely necessary. In “a timely manner” should be within a four hour

window of first being notified. Failure to pick the camper/teen leader up in a timely manner may result in

the local child services being called. Also, on the return day from camp, an approximate time is given in

the orientation packet. Failure to pick-up (within two hours of estimated time of arrival or actual arrival

time, whichever is latest) camper/teen leader by someone from the pick-up list provided by the

parent/guardian may result in local child services being called.

I have read and understand the above policy.

________________________________________________________________

Parent/Guardian/Adult Volunteer Date

Kentucky 4-H Camping Program

Damage Fees

The following contains only those items most frequently damaged or taken. Intentional damage to any other

camp property will be assessed at the time of damage. Should intentional damage or theft occur, it is the

responsibility of the child and his/her parents to reimburse the costs. No charges are made for worn equipment

or normal usage. Charges are required for damage resulting from horseplay and malicious or intentional

behavior. Graffiti on camp property will not be tolerated.

Fire Extinguisher Discharged or broken 75.00

Screen Door Repair or Replace 50.00

Bunk Bed Bed Replacement / repair Cost of replacement

Graffiti Defaced with Graffiti 50.00

Mattress Replacement 150.00

Smoke/CO Detector Damaged or missing 100.00

Windows Repair or Replace 100.00+

HVAC Controls Repair/Replace 100.00+

Cabin HVAC Replace or repair 1500.00+

Window AC Replace 250.00

Window Screens Replace 50.00

First Aid Kits Lost or missing 25.00

Brooms, Mops Broken or missing 20.00

Dust Pans Broken or missing 10.00

Trash Cans Broken or missing 25.00+

Basketball Rim Broken or missing 150.00

Basketball Backboard Broken or missing Cost of replacement

Cabin Keys Lost or missing or broken 10.00+

Changing Tents Damaged or missing 50.00

Other ANY DAMAGE TO ANYTHING NOT LISTED

INCLUDING PROGRAM EQUIPMENT WILL BE

BILLED AT THE COST OF REPAIR/REPLACEMENT.

I understand that I am responsible for paying for any damages that my child may cause to camp property.

__________________________________________________________________________ ___________________________________

Parent/Guardian Signature Date