2017 4-H Camp Registration
“At The Movies”
Registration is due to the Blaine County Extension Office by June 2, 2017.
Eligibility: Members enrolled in a regular 4-H Club and who are in the seventh grade or lower for the 2017-2018 school year.
Dates for Camp are June 12 – 14, 2017. Camp is held at Beaver Creek Camp Kiwanis (south of Havre) –
Out of County - Counties included in camp are: Blaine, Chouteau, Glacier, Hill, Liberty, Phillips, Pondera and Toole. Camp cost is $50.00. Please complete this form and return with payment to:
Blaine County 4-H Council, PO Box 519, Chinook, Mt 59523-0519
Questions: 357-3200 Checks need to be made payable to Phillips/Blaine 4-H Camp
Name: / Phone:Address: / City & Zip:
Age (at camp): DOB: / Male Female (circle one)
What kind of swimmer are you: (circle one) Poor Fair Good Excellent
PARENT: Can your child sleep on the top bunk? Yes No (circle one)
Two friends I would like in my cabin are:
Are there any restrictions to the following activities?
Fitness trail or hike Yes No Canoeing Yes No
Swimming Yes No
We will be providing a white t-shirt for each camper: Please circle the correct size.
Youth Sizes Small Medium Large X-Large Small Adult Medium Adult
Media Release Form
The Multi-County 4-H camp may like to use photos or video of your child that was taken during camp activities to use in a press release and other publicity related to this event. The photo or film may be used for the following purposes:
Website Press Release News Story Marketing Materials any other
Conditions of use:
1. We will not use personal details or full names of any child in a photograph on our web site.
2. We will not include personal e-mail or postal addresses, telephone or fax numbers on our web site or in other printed publications.
3. We may use the name of the child in accompanying text or a photo caption.
4. We may use group or photographs with very general labels.
5. We will only use images of children in suitable dress, to reduce the risk of inappropriate us of images.
Do you authorize the use of photos or video of your child at this event or activity?
_____ yes _____ no
I consent and agree, individually and as a parent or guardian of the minor named above to the foregoing terms and provisions. By signing below, I hereby waive any right that I (and a minor) may have to inspect or approve the copy and/or finished product or products that may be used in connection therewith or the use to which it may be applied. I warrant that I am of full legal age and have every right to contact for the minor in the above regard. I have also read and understand the conditions of use listed above.
Parent or Guardian Signature______Date______
CODE OF CONDUCT
1. Have fun and be safe! Participate in everything! Be on time!
2. Wear your name tag (except when sleeping, swimming or showering)!
3. Drink water regularly. You may want to bring a water bottle.
4. Be at the dock ONLY when lifeguard or canoeing instructor is present!
5. Stay on the premises!
6. If you feel sick, tell a camp nurse, counselor or adult!
7. Girls only in girls’ cabins, Boys only in boys’ cabin!
8. Wear appropriate clothing:
Swim suit when canoeing; appropriate clothes on at all times, hats off in dining room; shoes on outside.
9. Follow the direction of camp leaders.
10. I will conduct myself at all times in order to be a credit to the club.
11. I will show respect for the rights of others to be courteous at all times.
12. I will respect the property of others.
13. I will demonstrate sportsmanship in the contests and meetings, modesty in winning and generosity in defeat.
14. I will care for the lodging property and respect the rights of other campers of the cabin and observe all rules instituted by the property.
15. I will respect supervision at all times, being responsible to all adults and Counselors connected with the event.
I have read the above Code of Conduct and understand that my infraction of any of the above rules will be cause for my participation in the camp to be terminated and for me to be sent home at my own expense. I understand that attending camp is a privilege.Signature of 4-H Camper Date
Parent/Guardian Signature Date
4-H HEALTH INFORMATION
Participant’s Name / Parents or Guardians Names: / Phone: HomeCell: Mom
Dad
Emergency Contact: / Relationship: / Phone:
Physician to Contact: / Phone:
Dentist: / Phone:
Medical Insurance / Company: / #’s
There will be a nurse at camp.
Date of Last - this must be filled outTetanus Shot: / Polio Shot: / Mumps Shot: / Measles Shot: / Rubella Shot:
Medical Information: Check all that apply and explain if checked
Stomach or Intestinal ProblemsDiabetes or hypoglycemia (low blood sugar)
Nervous Disorder ( convulsion, epilepsy, dizziness, ect)
Respiratory problems
Heart Disease
Any allergies to medication
Any allergies to foods or plants
Use of an epipen
Special diet or food restrictions
Are us currently taking medications - if so name and dosage
In case of medical emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child. In case of minor emergency, I hereby give permission for the camp nurse or qualified camp staff to administer first aid. Parents will be notified of serious physical conditions requiring off-site medical attention.
I give permission for the camp nurse to administer non prescription medications to my child (check all that apply and state dosage):
_____Acetaminophen (Tylenol) ______Ibuprofen (Advil) ______Cough Syrup
_____Antacid (Tums, Mylanta) ______Antihistamine (Benadryl - for allergic reaction)
If your child is taking medication you must have it in the original container or an RX stating your child’s name and the correct dosage. You must also list the non prescription medication dosage. If your child has an epipen, they must be able to administer it themselves. If dosages and correct RX’s are not stated, medication will not be given and youth will not be able to attend camp.
Date and Signature of parent or legal guardian:CONSENT TO PARTICIPATE
Description of Event: Multi County 4-H Camp
This three day event held at Camp Kiwanis at Beaver Creek Campgrounds provides a variety of workshops such as canoeing, dance, and races. Campers sleep in cabins with an adult chaperon and teen counselor(s).
Consent: We, as parents of this minor child, acknowledge that we are aware of and understand the risks and hazards connected with the event and activities listed above. We understand that if we have any questions about this event and its activities, we can secure more information before signing this consent form by calling the MSU/Blaine County Extension at 357-3200. Checks need to be made payable to Phillips/Blaine 4-H Camp.
We further understand that we are assuming the risks of loss, property damage or personal injury that may be sustained by our child as a result of participating in this event. I hereby consent to my child’s participation in this event.
Date and Signature of parent or legal guardian:My Child will be dropped off by: / My Child will be picked up by:
2017 Camp Registration –Blaine
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