Registration Form
19th Annual Teen Involvement Conference
January 20-22, 2012
fb.com/4HTIC
Registration Fee: Early Bird: Application postmarked by December 11, 2011
Registration Fee - $110.00
Deadline: Application postmarked between December 12, 2011
and January 7, 2012: Registration Fee - $120.00
Late Registration: Application postmarked after January 7, 2012 or
handed to the check-in table at the conference:
Registration Fee - $150.00
No refunds of fees after January 13, 2012
Conference Information:
· The Teen Involvement Conference is open to all California State 4-H members aged 13-19 years old. Members must be 13 and not older than 19 by January 1, 2012.
· Ages must be verified by the local club leader with a signature located on this application form.
· All members must agree to the 4-H Code of Conduct and any rules set forth anytime during the conference by planning staff or chaperons.
·
Chaperon Information:
· For every 8 youth attending, one Chaperon is required or the youth will not be able to attend. If there are male youth attending the conference it is required that there is a male chaperon from the youth’s county.
· To be a chaperon at TIC you must be an enrolled 4-H leader and over the age of 21 or follow your county chaperone guidelines.
· NO ONE CAN LEAVE EARLY FROM TIC WITHOUT PRIOR PERMISSION!!!
*TIC REGISTRATION IS ON A FIRST COME, FIRST SERVE BASIS,
SO GET YOUR APPLICATIONS IN AS SOON AS POSSIBLE.*
Applications are required to have the following: signed application, signed code of conduct, signed medical release form, signed dress code sheet, and registration fee in the form of a CHECK or MONEY ORDER made out to the South Section Leaders Council.
Please mail completed application and registration fee package to:
Matthew Jones
874 Ronald St.
Brawley CA. 92227
(760) 344-1980
TIC Application
Name:______Age: ______
Mailing Address: ______
City:______Zip Code:______
County:______Phone #: ______
Email Address: ______
Member’s Signature:______
Parent’s Signature:______
Local Club Leader’s Signature:______
Phone #______
County Staff Signature:______
Phone # ______
Workshop Selection
Please select a first and second choice for each workshop. Every effort will be made to accommodate the first choice of each participant. Attendance to workshops is a conference requirement, and selection is on a first come first serve basis.
Workshop A 1st Choice______2nd Choice______
Workshop B 1st Choice______2nd Choice______
Workshop C 1st Choice______2nd Choice______
Workshop D 1st Choice______2nd Choice______
Please Attach, Completed: ~Code of Conduct
~Medical Release
- youth for participants
- adult for chaperones only
This is a leadership conference. All the delegates will be expected to participate in the workshops and to attend all general workshops. During these workshops no one will be allowed to stay in their cabins. If the delegate becomes ill they will be staying with the nurse in the medical cabin.
Please mail completed application and registration fee package to:
Matthew Jones
874 Ronald St.
Brawley CA. 92227
(760)344-1980
Items Needed for Success on the Island
Personal Items:
Sleeping Bag
Pillow
Towel
Washcloth
Toothbrush/paste
Soap/Shampoo
Warm Clothes (enough for 2 days)
Pajamas
Extra socks
Shoes (sandals/flip flops discouraged)
Jacket
Hat/Beanie (optional)
Mittens/Gloves/Scarf (optional)
Flash Light
Your Enthusiasm!!!!
Items to Share: (each delegate is asked to bring these items to share)
1 Snack Item for the community snack table (may bring more if you wish)
Items for Community Service Project (see page 6 of registration packet)
County Participation: (each county is asked to bring these items to participate in the opening ceremonies)
County Flag and Flag Stand
Poster Advertising County
At least one flat of water (more would be appreciated!)
Please come ready to talk about your county on Saturday afternoon. You may bring photos, fliers, or specific items that represent your county. Be creative! This presentation may be done as a group or you may choose 1 or 2 delegates to speak. You will have 3 to 5 minutes to make your county shine!
The South Section Teen Council is Proud to Present
Taking Life Head On!
Presented by: “Yo Pal” Hal Elrod
Hal Elrod has been known as “Yo Pal Hal” since hosting his first radio show at age 15. He became a national record-breaking sales rep for a 200 million dollar marketing company at 19, but his real triumph came at age 20 when he was hit head on by a drunk driver and found dead at the scene…
Defying the logic of doctors, he lived, and despite the temptations to be a victim, he worked his way back to become a bestselling author, award-winning keynote, youth, and college motivational speaker, international life & business coach, hall of fame business achiever, ultra-marathon runner, survivor of a near-fatal car accident, and most importantly – proud husband and father.
Hal has appeared on dozens of TV and radio shows across the country, and his story was featured in the all-time bestselling Chicken Soup for the Soul book series.
His bestselling book is Taking Life Head On! (The Hal Elrod Story) and he is the Creator of the not-so-obvious secret guaranteed to change your entire life (before 8:00 A.M.) known as The Miracle Morning®.
Workshop Sessions
Island Beaches
Gayle Champlin
“During your visit to ‘Leadership Island’ stop and play in the sand. Create a beautiful sand art bottle, keychain or necklace. This session is learning to relax with crafts. You will also be able to take this knowledge back to your club or county.
Mapping Citizenship Success
Tory Grainger
“This session will share with participants the different adventures to becoming aware of being a good citizen while searching for treasure. Interactive discussion and presentation of conferences and trips such as California focus, National Conference, National Congress, and possibly International Frontiers.
Start an Island Revolution! (Revolution of Responsibility)
Dayle Morris and Savanna Stanley – Ventura County All Stars
Have a problem in your county that needs fixing but you don’t know what to do? Come get some ideas on how to get others in your community involved in making a difference.
Powering the Island (Geothermal Energy)
Ernie Higgins – General Manager of Calenergy Operating Company
What is Geothermal Energy? How do they use it to make electricity? Learn how the science of Geothermal Energy powers our planet using our planet, and how California is on the cutting edge of this renewable energy source.
Cardboard Automaton: Simple Machines Workshop
Jessica Choi - California4-H Technology Leadership Team
The cardboard automaton is a hands-on, inquiry-based workshop that is low cost and environmentally friendly. This workshop is a fusion of art, as well as science, engineering, and technology (SET). Using shoe boxes that would otherwise be thrown away and common household items, such as straws and skewers, this workshop is perfect for underprivileged and individual groups and organizations.
Finding Hidden Treasure
John Trammell - California4-H Technology Leadership Team
Learn to use GPS technology to find hidden containers with GPS coordinates. Find out about this fast growing hobby called “Geocaching”!
Team Building – Making A List And Checking It Twice
San Bernardino All-Stars
Come learn to work as a team and how to teach others to do the same. But how do you know if you are succeeding? This session will also enable delegates and leaders to make a physical checklist to know if their team is running the correct way. In this session, they will be doing different activities to test their team. These activities are quick and easy letting the delegates take them back into their counties and clubs
Eat That Frog
Tony Burkhardt, South Section Teen Council Advisor
Riverside County 4-H Volunteer Leader
The secret to getting more things in less time. Bring pen, paper and a healthy appetite!
The Secret Of Life
Tony Burkhardt, South Section Tee Council Adviser
So what is the secret of life? How do I find this buried treasure? Let’s go and see if X marks the spot!
Community Service Project
Honoring Our Troops
To honor and thank our troops for the sacrifices they make for our country, we will be collecting items to ship to troops currently deployed in either Iraq or Afghanistan. These items will be shared by all troops n the area. Items you may contribute are:
Food Items
Individually Wrapped Candies (Twizzlers, Tootsie Rolls, Tootsie Pops, Skittles, Life Savers, etc)
NO CHOCOLATE – chocolate can melt
Small Packages (snack size) of nuts, seeds, pretzels, cookies, chips (Pringles in a can are best), Cracker Jacks, corn nuts, fruit snacks, and fruit leather
Trail Mix, energy bars, protein bars, breakfast and granola bars, nut bars, Instant oatmeal, Kraft Easy Mac, Ramen Noodles, and Cup-a-Noodles
Powdered presweetened drink mixes (Gatorade, Crystal Light, Kool-Aid), ground or instant coffee, tea bags, hot chocolate, cider mix, sweeteners, Coffee Mate, and condiment packets.
Canned meat (NO PORK!), stews, chili, ravioli, soups, fruit, beef jerky, non-refrigerated microwavable meals
Personal Items
Hotel/Travel size gel deodorant, shampoo, lotion, toothpaste, mouthwash, toothbrushes, dental floss, and Brush-Ups
Disposable razors, eye drops, nose drops, unscented baby wipes, wet wipes, small bottles of hand sanitizer, Mach 3 Turbo Razor Blades
Small Kleenex packages, Q-Tips (large packages are fine), anti-fungal creams, Band Aides, Foot powder, and sunscreen
DVD’s, CD’s, batteries (AAA and AA), pens, pencils, blank greeting cards and stationery, stickers, disposable cameras, AT&T phone cards, comic books, puzzle books, and paper-back novels
Ziploc Bags (all sizes) to make care packages
Hand written notes, cards, and letters of encouragement. We will be making these at TIC!
Quilts Of Valor
We are also making and sending quilts to the Quilts of Valor Project. If your county would like to participate by making a quilt to donate, go to
http://www.qovf.org/content/basic-qov-requirements.html
The quilts need to meet certain requirements. This site will give you all of the requirements for the quilts. The finished quilts will be given to wounded soldiers as they enter the hospital and will remain with them for the entire time they are recuperating. Then the quilt will go home with the soldier to become a permanent part of his/her home. It is a reminder of those of us who care.
It would be awesome if we could send several quilts to this project!!!
University of California Division of Agriculture and Natural Resources4-H Youth Development Program
Youth Medical Release Form
This Medical Release Form is authorized for all 4-H Youth Development meetings and activities during the dates specified below:
______
First Name Last Name Club/Unit Name
______to ______
County and State Dates (From / To)
While my child is attending or traveling to or from this 4-H function, I HEREBY AUTHORIZE THE ADULT 4-H VOLUNTEER LEADER OR 4-H STAFF MEMBER, or in his/her absence or disability, any adult accompanying or assisting him/her, TO CONSENT TO THE FOLLOWING MEDICAL TREATMENT FOR SAID MINOR:
Any x-ray 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 x-ray 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/guardian, I will be responsible for the cost of any service or treatment provided not covered by the 4-H Accident/Sickness Insurance Program sponsored by UC Cooperative Extension.
Emergency Contact Information______
Name Relationship to Youth Identified Above
(______)______(______)______
Emergency Day Phone (with area code) Emergency Night Phone (with area code)
______
Mailing Address City State Zip
Authorization and Consent and Release
I hereby certify that my child is in good health and can travel to and participate in all functions of the 4-H Youth Development Program as described above. I understand is it my responsibility to keep the information on this form updated (including Health History and parent/guardian status) by contacting the State 4-H Office.
______
Signature of Parent/Guardian Date
Non-Consent
I do not desire to sign this authorization and understand that this will prohibit my child from receiving any non-life threatening medical attention in the event of illness or accident.
______
Signature of Parent/Guardian Date
University policy and the State of California Information Practices Act of 1977 require the following information be provided when collecting personal information from you: The information entered on this form is collected under authority of the Smith-Lever Act. Submission of the medical data is voluntary. However, a signature is required on one or the other of the two signature lines above. Failure to provide the medical information and authorization may result in our inability to provide necessary 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 from the local UCCE County Director, 4-H Youth Development Advisor, 4-H Program Representative, or the State 4-H Director at the California 4-H Youth Development Program, University of California, DANR Building, One Hopkins Road, Davis, CA 95616-8575, (530) 754-8518. Only your own/your child's records are open to your review.
Any known or foreseeable intergovernmental transfer that may be made of the information is as follows: None.
University of California Division of Agriculture and Natural Resources4-H Youth Development Program
Health History Information
______/______/______
First Name Last Name County Date of Birth
Subject to: /
Yes
/ No / Now Have or Have Had / Yes / NoColds / Heart Trouble
Sore Throat / Asthma
Fainting Spells / Lung Trouble
Bronchitis / Sinus Trouble
Convulsions / Hernia (rupture)
Cramps / Appendicitis
Allergies / Has appendix been removed?
Wear corrective lenses? / Do you walk in your sleep?
Is hearing good?
Date of last Tetanus Vaccination: ______