OhioStateUniversityExtension

20174-H SUMMER CAMP REGISTRATION

HeldatCanter’sCave4-H Camp

1362CavesRoad,Jackson, OH45640

Inviteyourfriends! Youdonotneedtobeenrolledin4-Htoattend

4-H Camp. Anyageeligibleyouthmayattend4-H Camp.

Name ofCamper

Age

PleaseCircle:MaleFemale

Name of 4-H Club

County

Address

(StreetorPO Box)(City)(State)(Zip)

Name of Parent/Guardian

HomePhone( )

InCaseofEmergency,Contact:

Name Relationship

Phone( )

(Pleasecheck mark thecampyouwill beattending.)

Checkmark the camp you plan to attend: / Camp / Dates / Fee / Registration Due
STEM Camp / June 5th – 7th / $70.00 / April 17th, 2017
Beginner Camp (3rd – 5th grade) / June 8th – 11th / 4-H Rate: $136.00
Non 4-H Rate: $140.00 / May 15th 2017
Cloverbud Camp / June 16-17th / $55.00 to include first adult/cloverbud, each additional family member $25.00 / May 15th, 2017
Jr. High Camp (6th – 8th grade) / June 19th – 22nd / 4-H Rate: $136.00
Non 4-H Rate: $140.00 / May 15th, 2017
Teen Camp / June 23rd – 26th / 4-H Rate: $140.00
Non 4-H Rate: $145.00 / May 15th, 2017
Jr. Shooting Sports (9 – 12 years old) / June 30th – July 2nd / $225.00 / May 15th, 2017
Shooting Sports Camp (12 – 18 years old) / July 23rd – 28th / $325.00 / May 15th, 2017

PleasesubmitcompletedCampRegistrationFormsandcheckormoneyorderpayableto:

OSU Extension, LawrenceCounty

ATTN: CampRegistration

111 South 4th Street

Ironton, OH 45638

Ifyou have questions,pleasecontact:

Rachael Fraley,ExtensionEducator,4-H YouthDevelopment

(740) 533-4322

CANTER’SCAVE4-HCAMP,INC.

Elizabeth L. Evans OutdoorEducationCenter

CELLPHONE/ELECTRONIC DEVICEPOLICY AGREEMENT

•Campers andcounselorsarenot allowed to bringto camp anycell phone, iPod, handheld electronic game, tablet, laptop, orother communications device capableofaccessingtheinternet through WiFior another external network.

•Ifsuch adeviceis brought to camp byeitheracamperoracounselor, it will beheld bytheCounty

Extension EducatororCamp Directoruntil the conclusion of camp.

I,

(Printnameofcamper/counselor)

, understand thatIamnotto bringacell phoneorotherdeviceas

describedaboveto camp.

// SignatureofCamper/CounselorDate

Message toParents:

Weknowinthishightecherathatit’sdifficultforyouth tonotbeinconstantcontactwiththeirfamiliesand friends via Facebook, texting, or cell phone calls. However, camp is a unique experience. The campexperiencehelpsyouthdeveloplifeskillsincluding independenceandself-reliance.Among theconcernsthat makebringingand using cell phones and other communications devices inappropriateat campare:

•Concernthatsuchexpensivedeviceswillbelost,damaged,orstolen.OSUExtension,camp,andstaff cannot accept responsibilityforlost, stolen, ordamaged items at camp.

•Inappropriateuseofphotoandvideodevices.Weknowfrommediareportsthattheeaseofuploading inappropriatephotosandvideosisaconcern.Cyberbullying isnotpermittedbefore,during,or after camp.

Inaddition,youthcontactwithhomewhenthey aresufferingatemporaryspateofhomesicknessatcampmay causetheconditiontoworsen.Wefully appreciateandrespectthepositiverelationshipsourcampersand counselorshavewiththeirfamilies,butiftheyaretobenefitfully fromthecampexperience,they mustbe encouragedtodevelopthe skillsofindependence andself-reliance.Ifthere isanemergency,orifwe are concernedabouttheyouth’swell-being,wewillcontacttheparentsor guardiansimmediately.Campersare constantlyinthecompanyofothercampersandcounselorswhileatcamp,andourcampsarestaffedwith manycaring adults, includinganexperiencedcamp nurse.

I,

(PrintNameofParent/Guardian)

, have read the abovepolicyand agreeto the

guidelinesstated,includingthatthecellphoneorotherdevicewillbecollectedandheldby campstaffand returnedattheendofcampifthepolicyisviolated.Iunderstandthatifthereisanemergency andIneedto reach mychild whiles/heis at camp,Imaydo so bycontactingthecamp at (740)286-4058.

// SignatureofParent/GuardianDate

OHIO 4-HPARTICIPANT/MEMBERHEALTHHISTORY

Thisformmustbecompletedforeachparticipantbytheparents/guardiansofminors. Thisinformationwillbekept confidentialandusedonlyforthewelfareoftheparticipant.

DATE COUNTY

PLEASECIRCLE: MALEFEMALEAGEDATEOFBIRTH

NAME

(LAST)(FIRST)(MIDDLE)

ADDRESS

(STREET)(CITY)(STATE)(ZIP)

PHONE(HOME)GUARDIAN'SWORKPHONE

INCASEOFEMERGENCY,CONTACT:

PARENTNAME PHONE

CELLPHONE PAGER

OTHERPERSON PHONE

PHYSICIAN'SNAMEPHONE

DENTIST’SNAME PHONE

InstructionsforMedications

1.AllprescriptiondrugsMUSTbecarriedinthecontainerinwhichtheywereissued(with medicalordersandphysician'sname intact),andgiventothe nurse/healthdirector.Otherswillnotbeaccepted.

2.Ifyouneedover-the-countermedicationsnotlistedbelow,theymustbeinthe originalcontainerand mustbe storedunder lockandkeybythenurse/health directororaresponsibleadultduringthe 4-H event.

CHECKMEDICATIONSBELOW,THATPARTICIPANTMAYRECEIVEIFDEEMEDNECESSARY:

Ibuprofen/advil / Acetaminophen/tylenol / laxatives
antacids / tripleantibiotic / diarrheamedication
RobitussinCoughSyrup / adrenalin

LISTAPPROXIMATEDATEIFPARTICIPANTHASHADORBEENEXPOSEDTO: CHICKENPOXTUBERCULOSIS MEASLES MUMPS

WHOOPINGCOUGHSCARLETFEVERTETANUSIMMUNIZATION

DateofLastBoosterDateofLastMenstrualPeriod

OperationsorSeriousInjuriesrequiringmedicaltreatment(specify): Checkbelowifparticipantissubjectto:

headaches / fainting / hearttrouble / frequentcolds
constipation / convulsions / frequentsore throats / kidneytrouble
athlete'sfoot / sinusitis / bedwetting / sleepwalking
earinfection / epilepticseizures / homesickness / bronchitis
cramps / diarrhea / asthmacontrolled(yes,no) / other pleasespecify

Page1of2

CheckifParticipantisAllergicto:

Foods(specify) Medication: Prescriptionornon-prescriptiondrugs(specify)

SeriousIvy,Oak,orSumacPoisoning

BeeorInsectStings PrescribedTreatment

LISTALLPRESENTMEDICALANDALLERGICCONDITIONS (ContactLenses,Braces,Diabetes,etc.)whichrequire medication,treatment,orspecialrestrictionsorconsiderationsinparticipation.

Conditions:

Medications:

SPECIFYANYRESTRICTIONSINACTIVITIES(INCLUDINGSPECIALDIETNEEDS):

Immunization Record

Pleaserecordthe date(month& year)ofbasic immunizationsandmostrecentboosterdoses.

Vaccines / YearofBasicImmunization / YearofLastBooster
Diphtheria
Pertussis(whoppingcough)DPT* Tetanusor / 1
2
3 / 1
2
TetanusTD* Diphtheriaor
Tetanus
OralPolio(Sabin)*TOPV
InjectablePolio(Salk)
Measles(hardmeasles,redmeasles,Rubeola)
Mumps
Rubella(Germanmeasles,3-day measles)
Other
Tuberculintestgiven (mostrecent)
Hemophilusinfluenzab(HIB)

PARENT/GUARDIANMEDICALRELEASE

(Child’sname)hasmypermissiontoparticipate intheCampprogramandactivities (withtheexceptionofthoserestrictedactivitieslisted).Iunderstandparticipants willbesupervised.Iunderstandthecampstaffand volunteers,arenotresponsibleintheeventofaccidentalinjuryorillness,norforthe compoundedinjuryorillnesstothe participant's presentmedicalconditionslisted.IfurtherunderstandincaseofseriousinjuryorillnessIwillbenotified.IfIcannotbecontacted,I givemypermissiontotransporttheparticipanttoanappropriatefacilityandIgivetheattendingphysicianmypermissiontohospitalize, securepropertreatment,andtoorderinjection,anesthesia,orsurgeryforthe participantasnamedabove.

Signature Date

IgiveTheOhioStateUniversitypermissiontopublishinprint,electronic,orvideoformatthelikenessorimageofmychild.Irelease allclaimsagainst theUniversitywithrespecttocopyrightownershipandpublicationincludinganyclaimforcompensationrelatedtouse

ofthe materials.

Signature Date Page2of2

CANTER’SCAVE4-HCAMP CODEOFBEHAVIOR

COUNTY

1.Theuse, consumption, orpossession of alcoholicbeverages (liquorbeer,includingnon- intoxicatingbeer)and unlawful items, such as illegal non-prescription drugs, arenot permitted duringtheevent. Anyone arrivingforthe eventwhileundertheinfluenceof anyoftheabove substances will not bepermitted to register forCamp.

2.Participants arenot to leavetheCanter’s Cavegrounds for anyreason without theprior approval oftheExtension Agent in chargeoftheevent and permission form signed byaparent orguardian.

3.Males arenot permitted in the femalesleepingquarters nor arethefemalesallowed in themale sleepingquartersfor anyreason.

4.Campers will respect therights ofothers. Participants maynot invadethepersonal propertyof others norspeak to others in a foul oroffensivematter.

5.Participants will attend all events that areplanned in theprogram. Campersshould bewhere theyaresupposed to bewhen theyaresupposed to bethere.

6.Prescription drugs must beleft with theCamp Nurse. All illegal drugs oralcohol are prohibited on thegrounds ofCanter’s Cave4-H Camp.

7.Campers will beheldresponsible (financially)foranywillful damagedoneto Canter’s Cave4- H Camp orcamp property.

8.No oneis to go into theswimmingpool or aroundthelake except whenalifeguard is present.

Failureto obeydirections ofthelifeguardswill result in theloss ofswimmingprivileges.

9.A leaderineachcabin will organizethe cabin forevacuation in caseof fireorother emergency.

10.It is illegal to sell tobacco products to minors. Therefore, wediscourageuseoftobacco byall

4-H members. Theuseof anytypeoftobacco product is prohibited at 4-H Camp.

11.No pets of anysize, shape, or formwill bepermitted in camp.

12.Outsidevisitors arenot allowed in camp. IfaParent orGuardian finds it necessaryto visit, theyareasked to registerwith theCamp Directorimmediatelyupon arrival.

13.THISEVENT HASBEEN PLANNED WITH THE 4-H MEMBERSIN MIND. WE EXPECT THAT PARTICIPANTS FOLLOWTHE SET RULESANDBEHAVEINA RESPONSBILE MANNER. STAFFOFTHE OHIO STATE UNIVERSITY EXTENSION RESERVE THE RIGHTTOINFORM THE PARENTSAND SEND ANYINDIVIDUAL HOME AT ANY TIMEIFHE/SHE DOESNOTFOLLOWTHE SET RULESOF BEHAVIOR.

I haveprovided informationonthis formto thebest ofmyknowledgeandhaveread and understand theset rulesand guidelines for this event. I agreeto beanactiveparticipant inthis event and to represent my countyas a responsible4-H member.

SIGNATUREOF PARTICIPANT

SIGNATUREOF PARENT/GUARDIAN

DATE

NAME: ADDRESS:

Canter'sCave4-HCamp

ActivityLiabilityReleaseForm

AGE:PHONE:

EmergencyMedicalInformation

(If"Yes",pleaseexplainonthelinesfollowingthequestion.)

NOYESAllergiestofoods,drugs,insectbites,dust,etc.Please identifythemandthe natureofyour reaction.

NOYESPhysicaldisabilitiesorconditionswhichmightlimityourparticipation:

NOYESIfyouare presentlytakingmedication(s),pleaseidentifythem:

InCase ofEmergencyContact:

··NameRelationshipHomePhoneWorkPhone

StatementofUnderstanding

Iamawareinsigningthis statementforparticipationinprogramsofCanter'sCave4-HCampthatcertainactivitiesarephysically demanding.Therefore,physical fitnesswill increasetheenjoymentandabilitytoparticipateintheactivity.lffor anyreasonI questiontheabilityoftheparticipanttoparticipate intheactivity,Iwillconsultwiththeinstructorspriortopmiicipation.Whileitisimpossibleto foreseeallpossibledangers,someofthespecifichazardswhichmightbeencounteredwhileparticipatinginadventureprogramsinclude: HighRopesCourse,InitiativesCourse,Archery,RappellingArea,ShootingSportsCourse, andHikingTrailsinclude:slippingorfalling onthetrail,bumps,bruises,cuts,insectbites,poisonivy,sprains,fracturesorotherinjures.Iunderstandthatmostactivitiesare

conductedintheout-of-doorsin allkindsofweather,so properdress(raingear,warmclothing)areessentialtoavoidundueexposureto knownrisks;however,asaparticipant,Iacknowledgethenatureoftheactivityandthefactthatnotallofthestressesand hazards connectedwiththeactivitycanbeforeseen.

Ihavethepersonalresponsibilitytofollowtheestablishedsafetyrulesand proceduresto theextentthatI participateinsuchactivities. If atanytimeIhavequestionsabouttheactivity,Ihavetheresponsibilitytoconsultwithmyinstructor.Sponsoringagencieshavethe responsibilityofprovidingaprogression ofappropriateactivities,whichleadto theexperiencesatCanter's4-HCamp.

Irecognizethat thereisasignificantelementofriskin anyadventure,sport oractivityassociatedwiththeoutdoors.Knowingthe inherentrisks,dangersandrigorsinvolvedintheactivities,I certifythat the participant(includinganyminorchildren)isfullycapable ofparticipatingintheactivities.

I assumefullresponsibility forthe participant (includingminorchildren),forbodilyinjury,death,lossofpersonalpropertyand expenses thereof,asaresultof mynegligenceorthenegligenceofthe participant.

Signature

(Parentorlegalguardianmustsignforallpersonsunder 18yearsofage.)

Note:Allparticipantsshouldwear long pants(noshorts)andtennisshoesonthehighropescourse.

Date

TheElizabethL.EvansOutdoor Education Center

Canter’s Cave4-HCamp

• FromColumbus:

FollowUSRoute23(South)fromColumbustoChillicothe.TakeUSRoute35(EAST)in

ChillicothetowardsJackson.Afterabout(22)twentytwomilesonUSRoute35(EAST)you

willcometoagreenandwhitehighwaysignindicating “Canter’sCave4-HCamp1mile. Immediately turnLEFTontoTownshipRoad#223(CavesRoad).Followthisroadfor approximately(1)onemile.TurnLEFTontograveldriveattheElizabethL.EvansOutdoor EducationCenterCanter’sCave4-HCampsign.FollowgravelroadtoMainLodgelocatedat endofgraveldrive.

• FromDayton:

TakeUS Route35 (EAST)toChillicothe.FollowdirectionslistedabovefromColumbus.

• FromCincinnati:

TakeUSRoute32(EAST)toJackson.AttheintersectionofUS32andUS35,turn(WEST)

ontoUS35(towardChillicothe).FollowUS35forapproximatelyfive(5)miles,youwillcome

toagreenandwhitehighwaysignindicating“Canter’sCave4-HCamp1mile.Immediately turnRIGHTontoTownshipRoad#223(CavesRoad).Followthisroadforapproximately(1) onemile.TurnLEFTontograveldriveattheElizabethL.EvansOutdoorEducation Center Canter’sCave4-H Campsign. Follow gravelroadtoMain Lodgelocatedatendofgraveldrive.