Summer Camp Registration Form
4-H Members! Register Early for Summer Camp!
January 5- February 28,2015
Register between January 5th and February 28th, 2015 and pay a discounted rate of $180 AND register for any or all camp sessions!
Your completed registration form MUST go to your Local Extension Office and be received/postmarked no later than February 28th.
4-H Members who register after February 28 will pay the full non-4-H member fee of $225.
Please use a separate registration for each camper. PLEASE PRINT
Camper’s name __________________________________________________________________
□
Male□
Female Age: ______ years # Siblings also attending this camp session ______ County of residence_____________ How many years (including this year) have you attended 4-H Camp? ______ Parent/Guardian name____________________________________________________________Parent/Guardian address___________________________________________________________________________________ (Street) (City) (State) (Zip code)
Home phone______________________ Work Phone____________________ Cell Phone______________________________ Alternate contact if parent not available_______________________________ Phone__________________________________
IMPORTANT! Email Address: __________________________________________________________ Note: This Email will be used for your confirmation, your packing list and any other information that prepares you for camp.
4-H MEMBER CAMP FEE: $180 per camper
Any current 4-H Member may register for ANY camp week session - There are no specific County Weeks
Participating Counties: Champaign, Christian, Clark, Clay, Coles, Crawford, Cumberland, DeWitt, Edgar, Effingham, Fayette, Ford-Iroquois, Fulton, Henderson, Henry, Jasper, Jersey, Knox, Livingston, Logan, Macon, Macoupin, McLean, Mason, Mercer, Rock Island, Montgomery, Moultrie-Douglas, Peoria, Piatt, Rock Island, Sangamon, Shelby, Stark, Tazewell, Vermilion, Woodford ***If YOUR County is NOT listed, please send your registration & payment to the Camp directly
I want to attend this Camp Week:
Camper check-in – office use only
Cabin number_______________Overall feeling_________________ Recent illness (within last 10 days)____________________ Current medications______________ Special dietary needs______________
The 4-H Camp is a place that does not allow the following items brought to camp: knives (even pocket knives), alcohol/tobacco, firearms or cell phones iid you bring any of these items with you today?______________
Page 2 of registration form complete and with parent signature?___________________ Person conducting interview______________________
Page 1 of 5 Camp Week 1 Sunday, June 7 - Thursday, June 11
Camp Week 2 Sunday, June 14 - Thursday, June 18 Camp Week 3 Sunday, June 28 - Thursday, July 2 Camp Week 4 Sunday, July 5 - Thursday, July 9
My Bunk Mate Choice is:
______________________________________________ You may list one, same-gender bunk mate of comparable age
We do make every attempt to accommodate bunk mate requests, however, it is not always possible
If you are a 4-H Member from a County that is not listed on the front, please send your completed registration forms directly to: 4-H Memorial Camp at 499 Old Timber Road, Monticello, IL 61856. If you have questions, please call us at 217-762-2741.
Registrations must still be received by the deadline in order to receive the 4-H member discount. Please make your check payable to the 4-H Camp, if paying the camp directly.
Need to cancel? No worries! Please read carefully:
Central Illinois Camping Association Refund policy: $150 of fee refundable if cancellation is 7 days or more prior to camping session. No refund when the cancellation is made 6 days or less prior to the first day of camping session.
Your refund will be processed by your Local Extension, unless you paid the Camp directly.
STOP! Do you have everything?
Checklist:
• COMPLETED AND SIGNED SUMMER CAMP REGISTRATION FORM? • COMPLETED AND SIGNED HEALTH FORM?
• COMPLETED AND SIGNED AGREEMENT TO ASSUME RISK AND RELEASE FROM LIABILITY FORM? • PAYMENT FOR YOUR LOCAL EXTENSION OFFICE
• TURNED IN BY DEADLINE (FEB 28TH, 2015)
Page 2 of 5 Residence
Farm (where income is earned farming) Rural/Small Town (under 10,000) Medium Town (10,000-50,000) Suburb greater than 50,000 City greater than 50,000
Ethnicity (optional)
Hispanic or Latino
Yes
No Race: (select one) American Indian/ Alaskan Native White
Asian 2 or More Races
Black or African American Some Other Race Native Hawaiian or Pacific Islander
•
University of Illinois • U.S. Department of Agriculture • Local Extension Councils Cooperating University of Illinois Extension provides equal opportunities in programs and employment.
The 4-H Name and Emblem are Protected Under 18 U.S.C. 707.
Parental Consent
I give permission for my child to participate in all camp activities including swimming, boating, climbing, team challenge course, shooting sports, and out of camp travel into adjacent Robert Allerton Park when it is part of the camp program. I understand my child will be informed of the Illinois 4-H behavior guidelines and 4-H Camp code of conduct which stress a demonstration of the character traits of trustworthiness, respect, responsibility, fairness, caring, and citizenship. Should a
child display a blatant disregard for these rules; I will be notified to come pick up my child from the camp program. I grant the University of Illinois Extension 4-H Youth Program, irrevocable permission to record and/or disclose my child's
identity, image, and voice arising out of documenting 4-H youth programs and to use, reproduce and distribute such in whole or in part in video and/or sound recordings, films, photographs, transparencies, webpages, social media, local news
media or any other media for any purpose on behalf of the University and Extension without compensations to me and without any right for me to inspect or approve of the finished photograph, video, or audio recordings or other recordings.
Parent/ Guardian Name (Please Print Clearly)___________________________________________________
Parent/Guardian Signature
______________________________________________________ Date __________________CONFIDENTIAL
HEALTH FORM
4-H Memorial Camp
This form must be completed for each child by the parent/guardian and information will be kept confidential for the child’s welfare.
Please circle: Male Female Date of Birth___________________________ CampWeek _________________________ CAMPER'S NAME ________________________________________________________________________________________________
(First) (Last)
Parent/Guardian Name______________________________________________
Phone__________________________________________________
ALL medications, prescription and non-prescription, MUST be in the original container in which they were issued (with medical orders and physician's name intact), and given to the nurse/health director during camp session. Check Over-the-Counter Medications That Your Child May Receive if Deemed Necessary:
Antiseptics Diarrhea medication Antibiotic Ointment
Benadryl Non aspirin pain
medication
Is this camper current on immunizations required to attend school in Illinois?
YES_______ or NO________ If no, please explain____________________________
Last Booster: Tetanus___________
Check Below if Your Child is Subject To:
Lung Disease (asthma or tuberculosis) Heart or Cardiac Condition Kidney Problems
Migraines Sleep Walking Nervous or Mental
Conditions
DETAIL OF OTHER MEDICAL
CONDITIONS:______________________________________________________________
History of ALLERGIES (check those that apply, then provide detail below)
Bee Stings Food Allergies
Allergies to Medicine Other Allergies
DETAIL OF ALLERGIES:_____________________________________________________________
Please List Your Child’s Medication(s) That Will be Brought to Camp (If none, please indicate with N/A) :
Name of Medication(s):
_________________________________________________________________________________________________________________ Dosage(s)
_______________________________________________________________________________________________________________ Circle Time(s) When Medication(s) Need(s) to be Administered: 8 am Noon 6 pm 9 pm Other ________________
Page 3 of 5
CONFIDENTIAL
HEALTH INFORMATION STATEMENT
Check below any information you feel staff and/or volunteers may need, to maximize the safety and the well being of the exhibitor or staff member. To the right of the condition statement is space for more information relating to the condition checked. Please be specific. In case of emergency, this health information may be the only source of accurate, important information.
[ ]
Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever) _________________________
_________________________________________________________________________________
[ ]
Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis)
_________________________________________________________________________________
[ ]
Arthritis, Diabetes, Kidney or Bladder Disease ___________________________________________
_________________________________________________________________________________
[ ]
Impaired Sight or Hearing, Chronic Ear Infections_________________________________________
_________________________________________________________________________________
[ ]
Recent Surgical Operation, Accidents or Injuries_______________________________________
______________________________________________________________________________
[ ]
Any Infectious Disease___________________________________________________________
______________________________________________________________________________
[ ]
Skin Disease____________________________________________________________________
______________________________________________________________________________
[ ]
Under on-going care of a Physician (NAME & PHONE #) for chronic or recurring problem
______________________________________________________________________________
[ ] Do you wear glasses? YES [ ] NO [ ] SOMETIMES [ ] [ ] Do you wear contact lenses? YES [ ] NO [ ] SOMETIMES [ ]
[ ] Date of last FLU SHOT __________________________________________________________________ [ ] Significant Orthopedic and/or Neuromuscular Impairment (e.g. loss of limb, spinal cord injury)
Primary Care Physician: _______________________________________________________________________ Clinic/Hospital Affiliation: _______________________________________________________________________ City: _____________________________State: ______________Phone: (____)_____-______________________ Health Insurance Provider: _____________________________________________________________________ Owner's Name: ____________________________________ ID/Policy Number: ___________________________ Medical Privacy Statement: It is the policy of University of Illinois Extension 4-H Youth Development Programs to keep any medical information it may
have regarding 4-H Youth Development program participants confidential. However, there may be time in which such medical information will be needed and may need to be shared with others. Examples of sharing might include: providing information to medical personnel in the event of an emergency so that a youth may be treated; providing information to Extension staff or volunteers who are coordinating specific events in the case of a request for reasonable accommodation; and providing information to chaperones or host families who are responsible for the health and safety of program participants at a specific event. Except in the case of emergency, prior to sharing any medical information, it may have with those external to the University, Extension, or 4-H, every effort will be made to get the permission of the program participant or parent or guardian.
As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given. I further understand that in case of serious illness/injury, I will be notified. However, if it is impossible to contact me, I give my permission for emergency treatment, x-ray or surgery, as recommended by an attending physician.
I also understand that any accident insurance in effect (IF PROVIDED) for the event does not cover pre-existing conditions or self-inflicted injuries.
SIGNED:___________________________________
DATE:________________________
Parent or Guardian
Issued in furtherance of Cooperative Extension Work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture,
University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension provides equal opportunities in programs and employment. *The 4-H Name and Emblem are Protected Under 18 U.S.C. 707.
AGREEMENT TO ASSUME RISK AND RELEASE FROM LIABILITY
4-H Medium to High Activity
NAME OF EVENT: 4-H Summer Youth Camp DATE(S) all June and July sessions YEAR 2015 This is a legal document. You must read and understand it before signing it. The Activity is a residential summer youth camp.
I acknowledge that there are certain risks, hazards and dangers, including risk of physical injury, disability, or death and risk of loss of use or damage to my personal property as a result of allowing my child to participate in this Activity. 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 from the use of equipment, materials, or facilities recommended by the University of Illinois; environmental conditions; from the acts or omissions of others; or from the unavailability of immediate and/or adequate emergency medical care. I understand that the University of Illinois does not guarantee the personal health or safety for participants, nor does it protect against risk of loss of personal property.
I verify that I have knowingly disclosed all pertinent medical and health information about my child in the UI Extension 4-H Program Youth Emergency Medical Information form, which I have completed and signed. (May be crossed out if not applicable.)
If my child is injured or becomes ill, and/or causes harm to another person or another person’s property while participating in this Activity, I will accept responsibility for any losses and medical bills, including co-payments and deductibles not covered by the American Income Life Medical/Accident insurance policy, if purchased in conjunction with this Activity. I will not seek reimbursement from the University of Illinois.
I understand the University of Illinois does not assume responsibility for events that are not part of the Activity described above, or that are beyond the control of the University, its employees, its agents, or its volunteers, or for situations that may arise due to the failure of the participant to disclose pertinent information.
My child and I understand and agree to abide by the Youth Behavior Guidelines provided by University of Illinois Extension 4-H. I understand that the UI Extension has the right to ask my child to leave the Activity if a UI representative deems that my child’s behavior or action poses a threat to others participating in the Activity.
I affirm I have reviewed and understand the pertinent safety policies. (May be crossed-out if not applicable.)
In consideration for allowing my child to participate in the Activity, I release the Board of Trustees of the University of Illinois, its officers, employees, agents and volunteers from any and all liability, and waive any and all claims that my child and I may have, arising out of or in any way connected with the Activity and my child’s participation in the Activity. This release and waiver is binding on my heirs, assigns and representatives.
Youth’s Name____________________________________________________________________________
Parent’s Name Phone _____
Address City State Zip__________
Parent or Legal Guardian's Signature______________________________________________________
Assumption of Risk & Release 4-H medium to high physical activity/approved for legal form 052012 RM
