WHAT IS 4-H CAMP? 4-H camp is a fun opportunity for boys and girls to learn skills through hands-on experiences. The camping program helps youth build selfesteem and challenges them to be innovative and creative. Participants have the opportunity to participate in exciting. There are also swim and recreation times, special evening events, songs, games, and more.

Albemarle Charlottesville

A parent should know... Our camp is more than just FUN! It is also: Accredited through the American Camping Association Staffed with highly qualified staff and teen and adult volunteers Focused on the 4-H “Learn by Doing” motto & experiential learning model

Junior 4-H Camp also provides: A Junior Olympic-size swimming pool A secure setting with beautiful views on 150 acres of wooded land at Holiday Lake A ratio of 1 counselor per 8 campers

RETURN FORM AND PAYMENT TO: Albemarle/Charlottesville VCE 460 Stagecoach Road Charlottesville, VA 22902 MAKE CHECKS PAYABLE TO: Treasurer of Virginia Tech

July 2-6 Holiday Lake 4-H Center Appomattox, VA Cost $215 Scholarship Deadline May 1 Camp Class Sign Up May 18

"If you are a person with a disability and desire any assistive devices, services or other accommodations to participate in this activity, please contact Karrin Temple at the Albemarle/ Charlottesville Extension Office, (434) 872-4580 during business hours of 8:00 a.m. and 5:00 p.m. to discuss accommodations 5 days prior to the event. *TDD number is (800) 828-1120."

FOR MORE INFO, CONTACT: Karrin Temple Albemarle/Charlottesville 4-H Agent [email protected] 434-872-4580

REGISTRATION FORM CAMP SCHOLARSHIPS

Each year, local donors offer scholarships for campers who may not be able to afford camp otherwise. A $35 deposit is due with this form and the aid application which can be found on our blog or by contacting our office. The aid application is due May 1. Campers can also earn a full scholarship by competing in our 4-H County Contests in March. This is not need-based aid. Contact our office for more information. REGISTRATION INFORMATION Who can go to camp: Youth who are ages 9-13 as of Sept. 30, 2018. Youth at least 13 by Jan 1, 2018 are automatically enrolled as CITs. There is no extra training needed. Camp fee: $215 per child and includes all lodging, meals, classes, transportation, camp shirt, insurance, and other program costs. It does not cover souvenirs and snacks. You can pay in full, in monthly payments, or apply for a scholarship. There is a $50 fee on all returned checks. 4-H CAMP DATES TO REMEMBER May 1: Scholarship Applications Due May 18: Camp Class Sign-Up Night  

6:00 pm, Meeting Rm A, COB-5th St Final payments & outstanding paperwork due  Sign up for classes (first come, first served) July 2-6: 4-H Camp! REFUND POLICY: Cancellations must be made on or before May 18 for a full refund. Cancellations between May 19June 1 will only receive half of the camp fee. All fees are non-refundable after June 1. Virginia Tech processes all refunds which may take up to 30 days to receive.

CAMP DATES: July 2-6, 2018 Please turn in all attached forms plus a $35 deposit to reserve a spot for camp. Your spot is not guaranteed until final payment is made and all forms turned in. Camp slots are limited and it is first come, first served. Camper’s Name: ________________________________________________________ Mailing Address :

_____________

City:___________________________ Male ____

State ________________

Zip:___________

Female____ Birth date:_______________ Camper Age: (as of 9/30/18) _____

1. Race (check all that apply): 2. Ethnicity (check one):

White

Black

Asian

Hispanic or Latino

3.Did you attend 4-H Camp last year? 4. Where do you live (check one): 5. Grade in School: ____

Yes

City

American Indian

Alaskan Native

Native Hawaiian

Pacific Isl ander

Non Hispanic or Latino No

Suburb

County

Farm

Name of School: ___________________________________________

Parent/Guardian 1 Name : _____________________

Parent/Adult Contact Info

Parent/Guardian 2 Name : _____________________

Home Phone Work Phone Cell Phone Email Is this the primary contact person?

___ Yes

___ No

What is the best way we can contact a parent between 8:00 a.m.– 5:00 p.m?

___ Yes Home

Work

Cell

___ No

Email

SELECT YOUR PAYMENT OPTION: $215 Payment in full

$35 Deposit and scholarship application

$35 Deposit and $30/month payments (last payment due May 18)

Make checks payable to: Treasurer of Virginia Tech

OFFICE USE ONLY: Deposit Amount:

Cash

$35 Deposit

Check #_________________ $215 Payment in full

Forms Sent:_______________

Other:_____ Date Received:________

4-H Health History Report form Publication 388-906 Reviewed 2016

INSTRUCTIONS: Please provide detailed health information for determining appropriate supervision, support, and accommodations for the 4-H activity or event listed. A parent or guardian must sign. If the participant is a person with a disability and desires any assistive devices, services or other accommodations to participate in this activity, please contact your local Extension office during business hours at least 7 days prior to the event to discuss accommodations. PLEASE PRINT ALL INFORMATION. (NOTE: Both sides of this form must be completed.) Name of 4-H event in which you wish to participate: __________________________________________________________________ Date(s) of event: _________________________________ Location: ___________________________________________________ PARTICIPANT IDENTIFICATION Name: _________________________________________________________________________________

Last

First (Underline name by which you like to be called)

Middle

Female: ■

Male: ■

Mailing address: _____________________________________________________ Participant cell phone: ( ______ ) _______________ City: ____________________________ State: _____ ZIP: _____________ Home phone: ( _______ ) _____________________ Age: __________

Birthdate: ___________________ Home email: _______________________________________

Ethnicity (choose one): Hispanic/Latino ■

Not Hispanic/Latino ■

Race (choose all that apply): American Indian/Alaskan Native ■ Asian ■ Black/African American ■ Native Hawaiian/Other Pacific Islander ■ White ■ PARENT / GUARDIAN IDENTIFICATION (Place a check beside who to reach in the event of an emergency.) ■ First parent/guardian name: ________________________________ First parent/guardian email: ___________________________ First parent/guardian phone daytime: _____________________ Evening: ____________________ Cell: _____________________ ■ Second parent/guardian name: ______________________________ Second parent/guardian email: __________________________ Second parent/guardian phone daytime: _____________________ Evening: ______________________ Cell: _________________ Who has primary custody of the participant? ________________________________________________________________________ Address, if different than child: ____________________________________________________________________________________ 4-H PARTICIPANT MEDIA RELEASE

PHYSICIAN / INSURANCE INFORMATION Family physician name: _________________________________________________

Phone: ( ________ ) _________________________

Dentist/orthodontist name: __________________________________________

Phone: ( ________ ) _________________________

Do you carry family medical / hospital insurance?:

Yes ■ No ■



(Check ✔ one) Carrier: ______________________________________________



Policy ID #: _____________________________________________

EMERGENCY CONTACT INFORMATION (Parts 1 and 2 should be completed) 1. Where can you be reached in the event of an emergency? Location:___________________________________________________________ Phone: ( ______ ) __________________________

Cell phone: ( ______ ) _____________________

2. If you Cannot be reached, who should be notified? Name: ____________________________________________________________ Home phone: ( ______ ) ____________________

Work phone: ( ______ ) ____________________



Cell phone: ( ______ ) _____________________

The Virginia Polytechnic Institute and State University/College of Agriculture and Life Sciences (CALS) periodically uses electronic and traditional media (e.g., photographs, video, audio footage, testimonials) for publicity and educational purposes. By my signature on this form, I acknowledge receipt of this document and give permission to the College of Agriculture and Life Sciences and its designee to use such reproductions for educational and publicity purposes in perpetuity without further consideration from me. I understand that I will need to notify Virginia Tech/College of Agriculture and Life Sciences if any changes to my situation occur that will impact this media release permission. ■ Yes

■ No

(continued on back)

www.ext.vt.edu

* 18 U.S.C. 707

Produced by Communications and Marketing, College of Agriculture and Life Sciences, Virginia Tech, 2016 Virginia Cooperative Extension programs and employment are open to all, regardless of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, genetic information, veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; M. Ray McKinnie, Interim Administrator, 1890 Extension Program, Virginia State University, Petersburg.  VT/0516/4H-637NP

PARTICIPANT HEALTH AND MEDICAL HISTORY (Questions 1-5 must be completed.)

APPROVAL / EMERGENCY AUTHORIZATION

1.

(Please read parts 1 and 2. If the participant is under 18, parents/guardians must sign in the space provided. If you are over the age of 18, please sign for yourself. If you cannot sign this due to religious reasons, you must contact your Extension office to obtain a legal waiver that must be signed. If this section is not signed, participation in the 4-H event/activity will not be allowed. You must contact your Extension office if there is a change in health status after submitting this form.

S  PECIAL DIETARY NEEDS

INSTRUCTIONS: The purpose of this section is to communicate special dietary needs, food allergies, etc. for any child, teen, or adult who will be attending a 4-H event.

In the space below, please list all food allergies and/or other dietary restrictions for the person listed above and any necessary precautions that should be taken: __________________________________________________________________________

__________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

2.

H  as the participant ever experienced (or had special needs in) any of the following? [Check (✔) all that apply] ■  Asthma ■ Eating disorders ■ Diabetes ■ Fainting spells

■ Bleeding disorders ■ Seizures/Convulsions ■ Bed Wetting ■ Non-food allergies

■ Attention disorders (ADHD) ■ Wears contacts ■ Behavior ■ Other: ___________________

Please describe any condition or need that you checked: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

3. Is the participant experiencing any current health problems, under medical care, receiving mental or behavioral services, or currently taking medication?

■  YES ■ NO If YES, please explain: __________________________________ ___________________________________________________________________

4.

 as the participant undergone surgery, or experienced any injury, illness, allergy, H or change in health status any time during the last year? Is there any reason that participation in a program or activity should be restricted? ■  YES

■ NO If YES, please explain: __________________________________

___________________________________________________________________

1. I give my permission for the participant named on this form to attend the designated 4-H program. He / She has permission to participate in all activities which may include swimming and other water sports under the supervision of lifeguard(s) and to take part in other scheduled activities such as firearm safety, horsemanship, archery, low ropes, physical activity/exercise and related activities under the supervision of instructors; subject to limitations noted herein. 2. I hereby give permission to the medical staff person selected by the event/activity director to order X-rays, routine tests and treatment for my child (or for myself if I am a participant over 18 years old) as medically necessary. I also give permission for the participant to receive overthe-counter medication as needed under the guidance of the medical staff person. I understand that all attempts will be made to notify parents/guardians of any serious injury or illness to their child. If I cannot be reached in an emergency, I hereby give permission to the medical staff person to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for me/ or the participant named on this form. This form may be photocopied for use outside of the event/activity location. ADULT PRINTED NAME: ________________________________________________ SIGNED: X______________________________________ (Parent / Legal Guardian or participant over 18 years old)

Date: _______________________ I understand and agree to abide with any restrictions placed on my activities according to this form.

5. What else should we know about your child? 4-H programs include very rewarding, but sometimes challenging situations. Please inform us of any concerns that may arise related to your child’s physical, mental, emotional, and/or social health in order that we may better provide appropriate supervision and support.

______________________________________________________ ______________________________________________________ ______________________________________________________

YOUTH PRINTED NAME: ________________________________________________ SIGNED: X______________________________________

(Participant under 18 years old)

Date: _______________________

IMMUNIZATION HISTORY (This must be completed) Are your child’s immunizations up to date? ■ YES ■ NO

Date of most recent tetanus shot: (month/year) _______/_______

RELEASE AUTHORIZATION I give permission to the following individual(s) to pick up my child at the conclusion of this 4-H event: Name(s): ________________________________, ________________________________, _______________________________ Sign below at time of pick up (Receiving person must be pre-listed above): Name (print): _______________________________

Signature: _______________________________ Date: ________________

www.ext.vt.edu

*

Publication 4H-164NP

www.ext.vt.edu

*18 U.S.C. 707

Produced by Communications and Marketing, College of Agriculture and Life Sciences, Virginia Polytechnic Institute and State University, 2016

Virginia Cooperative Extension programs and employment are open to all, regardless of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, genetic information, veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; M. Ray McKinnie, Interim Administrator, 1890 Extension Program, Virginia State University, Petersburg. VT/0416/4H-609NP

www.ext.vt.edu

2

Albemarle/Charlottesville Junior 4-H CAMP Financial Assistance Application Please complete one application per child. To apply, please return this competed form by May 1st to: Albemarle County Extension Office 460 Stagecoach Roach Charlottesville, VA 22902 All information provided in this application will remain confidential and will be shredded after use. Child’s Name: Age:

Phone: Birthdate:

Years in 4-H:

Address:

School Child Currently Attends: With whom does the child reside?

Grade: □Mother

□ Father

If other, Name:

□Both

□Other

Relationship:

Father’s Name:

Occupation:

Employer:

Mother’s Name:

Occupation:

Employer:

Number of Other Children in Household:

Ages:

Approximate Household Income: Please include a copy of your most recent federal tax return or a statement from the school verifying that your child is on free/reduced lunch. Amount of Scholarship Requested (NOTE: Scholarships are available up to $180): Has this child attended 4-H camp in previous years?

□Yes

Has this child received a 4-H Scholarship in previous years?

□No □Yes

Does this child participate in the free or reduced lunch program? □No

If yes, year(s): □No

□Free

If yes, year(s): □Reduced

Is there additional information that you would like the scholarship committee to consider?

I certify that the above information is true and correct. I understand that my child may or may not receive a scholarship. Parent’s Signature: Date: Scholarship funds are generously provided by local Albemarle/Charlottesville residents, organizations, and businesses. Committee Use Only: Amount of scholarship awarded: Amount due from parent: