1999 for Campers Only 1999

TO: Adult Volunteers Interested in being Chaperones at

MarinCounty 4-H Camp 2011

FROM: Eileen Castelli, MarinCounty 4-H CampClerk

RE:Chaperone Application and Job Descriptions

Our MarinCounty 4-H Camp at Las Posadas, July 10 to July 16, is strictly a volunteer effort. We invite all interested adults to apply for a chaperone position. Please read the position descriptions and submit your application no later than March 1, 2011. Adult chaperones will be accepted following a selection process. If you would like to join us at camp for only ½ week, we will try to find someone for the other half. Adults who can attend the full week will be extremely helpful. In the event there are more chaperones than needed, we will develop a waiting list.

This year, our camping program will run from Sunday, July 10 through Saturday, July 16. The Adult Chaperone fee is $85.00. You may want to ask your club or group to help with your fees. Please read the following positions carefully and if you have any questions call Eileen Castelli at (707) 996-0354. We hope to hear from you soon.

ADULT CHAPERONE POSITIONS

There must be a ratio of one Adult Chaperone for each 10 youth in camp. These adults chaperone the campers in the sleeping areas during rest periods and bedtime. All adults take an active role in camp during assigned activities. The youth staff runs the camp and the chaperones are there to enhance the program only. “CAMP IS FOR THE CAMPERS” All adults must be fingerprinted through the 4-H program. If you have not been fingerprinted previously through the 4-H program, please request a fingerprint packet from the 4-H Office. (707)-499-4207 Fingerprints must be completed by June 1st.

ADULT CAMPSUPERVISOR: Coordinates camping program before and during week of camp. Works with Staff Advisor to train Youth Staff. Works with session advisors to implement programs. Reports to CampExecutive Committee and CampClerk. Must have three years MarinCounty 4-H Camp experience.

STAFF ADVISOR: Works directly with Youth Staff to plan, implement and coordinate camp. Coordinates staff training and advises staff at camp. Works closely with Adult Camp Supervisor. Must have two years MarinCounty 4-H Camp Experience.

SPECIAL EVENTS ADVISOR: Works with Special Events Directors to plan and implement activities and parties during week of camp.

CRAFT ADVISOR (S): Plans, coordinates, and implements camp crafts program during free time.

RECREATION ADVISOR: Works with staff to plan and implement a Recreation Program for camp.

CAMPFIRE ADVISOR: Works with Campfire Directors to plan campfire programs.

SPORTS ADVISOR: Works with staff to plan and implement all sports activities and tournaments during camp.

NATURE ADVISOR: Works with staff to plan and implement campOutdoor Education, Nature Sessions and free time hikes.

CAMPCHAPERONE: Will be assigned to a tribe to be a shadow during all events assisting tribe leaders as needed. Help with crafts, hikes, K.P., swimming and be a good, positive role model for the youth staff. Volunteers or will be assigned other jobs as needed.

Please note: The Staff and Adult overnight training weekend will beApril 30 – May 1, 2011 at Camp. Please make plans to attend this important weekend. More information on this to follow.

All adult leaders and chaperones must be fingerprinted to participate in the 4-H program.

Eileen Castelli, CampClerk

707/996-0354

Keep this page for your reference

2011 FOR ADULTS ONLY 2011

July 10 – 16, 2011

MARINCOUNTY 4H CAMP ADULT REGISTRATION AND MEDICAL TREATMENT FORM

Name______Currently Enrolled

in 4H Club (name)

Address______Phone

Birth date: ______Age: ______Sex: ______Year in 4-H______

Years at MARIN Co. 4-H Camp______

Ethnicity: (X) American Indian/Alaskan Native______Hispanic______Black______White______Asian/Pacific Islander______

Vegetarian? Food Allergy? What food(s)?

T-shirt Size (adult sizes only) Small Medium Large X-large XX-large

(A T-shirt and camp picture is included in the camp fee)

REGISTRATION: COMPLETE ONE FORM PER ADULT. After completing both sides of this form mail it with your signed Code of Conduct and CampFees ($85.00) (made payable to MARINCOUNTY 4H CAMP) to MARINCounty 4H Camp,

C/O Eileen Castelli, 840 Bowen Ct., Sonoma, CA95476. (Fees due no later than June 15th.)

I hereby certify that I am in good health and can travel to and participate in this 4H function.

While I am attending or traveling to or from this 4H function, I HEREBY AUTHORIZE THE ADULT 4H LEADER OR STAFF MEMBER,or in his/her absence or disability, any adult accompanying or assisting him/her, TO CONSENT TO THE FOLLOWING MEDICAL TREATMENT FOR MYSELF: Any Xray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Practices Act, California Business and Professions Code section 2000 et seq; or any Xray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered by a dentist licensed under the provisions of the Dental Practices Act, California Business and Professions Code section 1600 et seq.

This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective until my child completes his/her activities in this program unless sooner revoked in writing. I understand that as a parent/legal guardian, I will be responsible for the cost of any service or treatment provided not covered by the 4H Youth Accident Insurance Program sponsored by the University of California Cooperative Extension

I understand that participation in 4-H activities includes activities around animals and in the outdoors, and all the risks that accompany such activities. I therefore waive any claims and agree to release and hold harmless The Regents of the University of California 4-H Program, its officers, agents, and employees from any liability whatsoever.

______

AUTHORIZATION AND CONSENT AND RELEASE

______

Date signature of ADULT emergency phone DAY

Mailing address

City ZIP code emergency phone NIGHT

Should there be any changes in the status of parent/legal guardian, it will be my responsibility to keep the county officers informed.

University policy and the state of California Information Practices Act of 1977 requires the following information be provided when collecting personal information from you about your child The information entered on this form is collected under authority of the SmithLever Act. Submission of the medical data is voluntary. However, a signature is required on the signature line above. Failure to provide the medical information and authorization may result in our inability to provide ''ceded medical treatment. You have the right to review university records containing personal information about you/your child, with certain exceptions as set forth in policy and statute. Copies of university policies pertaining to the collection, use, or release of personal data are available for your examination at the Division of Agriculture and Natural Resources, 4-H,DANR, North Central Region, university of California, Davis, California, 95616 Only your own/your child's records are open to your review. Any known or foreseeable intergovernmental transfer which may be made of the information is as follows None. 2

HEALTH HISTORY INFORMATION

Name of Adult______SS#______

E-Mail address(please print)______

3
CODE OF CONDUCT

MARIN COUNTY 4-H CAMP RULES

LAS POSADAS STATE FOREST, ANGWIN, CALIFORNIA

1. Be polite and considerate of others and do not push, throw rocks, food, or any other items.
2. Sexual harassment is never permitted. Never use racial, sexual, or religious slurs.
3. Respect authority.
4. Respect the property of others and do not disturb it.
5. Respect the wildlife and do not harm any animals.
6. Practice safety: firecrackers, fireworks, slingshots, guns and knives are not allowed.
7. Preserve our camp atmosphere – do not bring alarm clocks, hair dryers, curling irons, food, radios, MP3 player, discman, electronic games, pagers, and cell phones.
8. Respect the camp schedule and always stay with the tribe or program to which you are assigned.
9. Closed toe shoes are required at all times. “Flip flops” may be worn in the shower only.
10. You may leave camp only with the permission of the adult Camp Supervisor and with 2 adults chaperone, parent or advisor to accompany you.
11. Hikers require permission from the Nature/Hike Leader; must sign out/in, and must be accompanied by two adults. Long pants, socks, and sturdy shoes will be worn on all hikes.
12. Alcohol and illegal drugs may not be brought to camp or be used at camp.
13. Smoking by campers is not permitted and chewing tobacco may not be used anywhere at camp.
14. Practice safety in camp: walk (do not run), and stay on trails.
15. Parking lot is off limits. No loitering or using vehicles while at camp.
16. Campers will remain in their assigned sleeping areas at night.
17. No boys in girl’s sleeping area, and no girls in boy’s sleeping area at any time.
18. Per 4-H policy, section 819, the person and property of all 4-H Youth Development Program (YDP) participants (both youth and adult) are subject to search during the course of 4-H YDP events if deemed necessary by 4-H YDP appointed volunteers and/or staff.

The penalty for infraction of these rules may result in any or all of the following:

1. Confiscation of inappropriate materials
2. Punishment as determined necessary by the Camp Review Team
3. Your parents will be called to come and take you home
4. You will be disaffiliated from the Marin County 4-H Youth Program

I HAVE READ THE CAMP RULES AND AGREE TO ABIDE BY THEM WHILE ATTENDING THE MARIN COUNTY 4-H CAMP.

______

Signature of Adult Participant Date

Please return CODE OF CONDUCT with your REGISTRATION/MEDICAL FORMS, WAIVER OF LIABILITY and FEES to EILEEN CASTELLI, 840 Bowen Ct. Sonoma, CA 95476.

Questions: 707/996-0354 or

4
CHAPERONE APPLICATION FOR MARIN COUNTY 4-H CAMP 2011

Name______

Address ______Telephone (___) ______

City______e-mail______

Zip ______Fax______

Currently enrolled in 4-H Club/Group______

Years with 4-H______Years Marin Co. Camp experience______

Please list any of your family that might be attending Camp with you so we can reserve a space for them.

Name ______Age______

Name ______Age ______

List your major interests and activities ______

What positions are you applying for?

1st Choice______

2nd Choice______

3rd Choice______

In what capacity are you working with youth at this time? ______

Complete the above application and sign the Code of Conduct/Camp Rules on the back of this sheet. Return along with the Adult Medical Release/Registration Form no later thanMarch 1st to:

Eileen Castelli

840 Bowen Ct.

Sonoma, Ca. 95476

707/996-0354

The above application is true and correct.

Signed: ______Date:______

5

Participant’s Name______

Please print

UNIVERSITY OF CALIFORNIA

DIVISION OF AGRICULTURE & NATURAL RESOURCES

4-H Youth Development Program

Marin County Cooperative Extension

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In Consideration of being permitted to participate in any way in California 4-H Activities and Projects, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue The Regents of the University of California, its officers, employees, and agents from liability from any and all claims including the negligence of The Regents of the University of California, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in California 4-H Activities and Projects.

______

Signature of Parent/Guardian of Minor Date Signature of Adult Participant Date

Assumption of Risks: Participation in California 4-H Activities and Projects carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions 3) catastrophic injuries including paralysis and death.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in California 4-H Activities and Projects. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the University of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in California 4-H Activities and Projects and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

______

Signature of Parent/Guardian of Minor Date Signature of Adult Participant Date

Participant’s Age (if minor) ______

6

University of California Division of Agriculture and Natural Resources

4-H Youth Development Program

Volunteer Confidential Self-Disclosure Form

______

Name of 4-H Club/UnitFirst NameLast Name

______

Mailing AddressCityStateZip

The purpose for requesting the information on this form is to provide a safe environment for young people involved with 4-H activities. Furnishing all information requested on this form is mandatory. Failure to provide this information will delay or prevent appointment as a 4-H Volunteer. Local programs may also require additional information before appointing 4-H volunteers. University of California policy authorizes maintenance of this information. Individuals have the right to review their own records in accordance with the Division of Agriculture and Natural Resources Administrative Handbook, Section 402. Information on these policies may be obtained from the Controller and Business Services Director, Agriculture and Natural Resources, University of California, 1111 Franklin Street, 6th Floor, Oakland, CA 94607-5200, or via the Internet at: The official responsible for maintaining the information contained on this form is the Cooperative Extension County Director.

1. Have you been convicted of a felony in the last ten years? Yes No

1. Has anyone living with you been convicted of a felony in the last ten years? Yes No

1. Have you ever been convicted of child abuse, neglect, or any sex offense? Yes No

1. Has anyone living with you ever been convicted of child abuse, neglect, or any sex offense?  Yes No

1. Has your driver’s license been suspended or revoked in the last ten years? Yes No

1. Are there any other facts or circumstances involving your background or background of Yes No

others in your household that would call into question your being entrusted with the

supervision, guidance, and care of young people?

1. Do you have a valid driver’s license? State______ Yes No

1. University of California (UC) requires volunteers to maintain minimum automobile liability

coverage of $50,000 per accident claim/$100,000 in aggregate/ $50,000 for property damage.

Do you have this level of coverage? Yes  No

If no, what is your coverage? ______per accident, ______in aggregate, ______property damage?

9. I understand that UC provides secondary liability coverage in the event of an accident during

4-H business and if my coverage is below the UC minimums, I am liable for the difference

between my policy limits and UC’s secondary coverage. ______initial

10If you answered “Yes” to questions 1-6, or “No” to 7 or 8, please explain:

By signing below, I certify that the information above and on my application is true and correct. In addition, I have read, understand and agree to the terms of the 4-H Code of Conduct/Responsibilities and Rights and Photograph and Information Release. I am aware that I must re-apply for a 4-H Volunteer appointment annually, and provide an updated Adult Medical Release Form, Waiver of Liability, and Volunteer Confidential Self-Disclosure Form. I also understand that this application must be approved and my fingerprints cleared through the Department of Justice before my service as a volunteer begins. Volunteer appointments are for a period of one year.