Dear Parent/Guardian and Camper,

This application packet is for the 2018 Fayette County 4-H Summer Camp! In this packet you will find all of the information you need to register for summer camp. Please read this entire packet to ensure you are informed of all our changes this year. Upon receipt of the completed registration and fee, you will receive a confirmation letter.

A camper newsletter will be mailed approximately 2 weeks prior to camp with details about what to pack, departure day, current medications, and other reminders. The 4-H staff looks forward to a terrific camp season for 2018!

If you have any questions about 4-H summer camp you can contact Chaquenta “Quen” Smith Neal by email at clsm224@uky.edu or by phone at 257-5582.

Kevin Lindsay Chaquenta “Quen” Smith Neal

County Extension Agents for 4-H Youth Development Education

To Register Send completed registration packet and fee to:

Fayette County 4-H Camp, Fayette County Extension; 1140 Harry Sykes Way Lexington, KY 40504.

Please be sure to include - payment, parent signature and a copy of the camper’s health

insurance or medical card. INCOMPLETE REGISTRATION WILL BE RETURNED

YOUR CHILD WILL NOT BE CONSIDERED REGISTERED UNTIL ALL REGISTRATION PAPERWORK HAS BEEN

RECEIVED - THIS WILL RESULT IN THEM BEING PLACED ON A WAITING LIST.

All items must be completed to be fully registered. Please see note on next page about healthcare forms.

4-H CAMP 2018 Date and Location

Monday, July 30 - Thursday, August 3, 2018 J.M. Feltner 4-H Camp

London, KY Theme: 4-H Camp: It’s Out of This World

Camper’s Age Ages 9 - 13

(must turn 9 before the first day of camp) Campers do NOT have to be current

4-H members to attend summer camp

Cost Campers: $ 250.00

Junior Counselors (16-19 Year Old Campers): $78.00 Counselors in Training (14-15 yr. old campers): $250.00

Includes transportation, 4 nights lodging, meals, snacks, class fees and T-Shirt

Payment accepted: Check, Money Order

Made payable to Fayette County 4-H Camp with your child’s name in the memo

NO CASH ACCEPTED Attention: WE ARE NO LONGER ACCEPTING CREDIT

CARDS DUE TO UK POLICY CHANGES

Volunteers Adult and teen volunteers are needed for a

successful camp week. We cannot take campers without adult counselors. One relative of an adult

camp counselor per camp session goes for 50% off. Adult counselors will attend camp for free. Any adult (ages 20 and above) or teen (ages 16 -

19) interested in being a volunteer should contact the 4-H Office at (859) 257-5582 or

e-mail: clsm224@uky.edu to request an application.

Deadlines The campers registration deadline:

June 29th, 2018 Our Camp session will be filled on a first come, first

serve basis, so don’t delay. Note: Incomplete registrations will be returned for

completion and your child will be placed on a waiting list until this paperwork is complete.

All camp counselor applications (Adult, Junior Counselors and Counselor In Training) are due

May 18th, 2018

Please be sure the entire registration/application is complete.

Scholarships

A scholarship is given based on the funds that are available to any child that qualifies. If you wish to apply for a scholarship, please submit both the scholarship application and a completed camp registration form. A non-refundable $25.00 application fee must be submitted with all paperwork.

Please note: Scholarship applications are available upon request Contact FCES Office for Application.

For Fayette Co. Residents only. Deadline: June 29th, 2018

Health Care

The Health Care Recommendations section must be completed. Please provided information on the child’s medical history, food, medical, dietary or other allergies. We need all this information to ensure a safe and fun week at camp.

ALL Camper Orientation *Mandatory*

Tuesday, July 24th, 2018 Returning Campers: 6:00 p.m.

New Campers: 7:45 p.m.

Location: Fayette County Extension Office

Pick-Up Information

In the Pick-Up/Release section on the registration form you must complete this section about

picking your child up. Please include the following information on the form:

Individual Name(s)

Relationship to Child Phone/Cellphone Number

Please note, return date is Friday, August 3, 2018

Time/Location TBA in camp newsletter

Attention UK Employees: A child of a UK Employee will receive a 20%

discount on the Camp Fee for camp. Parents must submit a copy of a valid UK Employee ID. (note: employee discount cannot be combined

with other discounts or scholarships.)

Classes In an effort to ensure students get an equal opportunity to pick their classes, we will now have class sign up at camper orientation. Please make plans to attend the mandatory camper orientation for sign-ups. If a child misses orientation, it will limit the class availability for your child.

T-Shirt Design Contest

Do not forget about our First ever T-Shirt Designing Contest. The Camper that has the best t-shirt design

will win a $200.00 Camp Scholarship. Open to Fayette Co. Residents only.

Deadline is July 1st, 2018. Do not miss out!!!

Kentucky 4-H Camping Program 2018

Camp Participant Registration – Camper/Teen (Ages 5 to 17)

Last Name:

Legal First Name: Middle Name: Preferred Name:

Attended camp before?

Yes - # years: ___ No

School grade entering:

What school does the camp

participant attend?

Gender:

M F

Shirt Size: (Circle One)

YS YM YL AS AM AL AXL A2XL A3XL A4XL

Birthdate:

______ / ______ / ______

How old will the

participant be on the first

day of camp?

Participant’s home address:

Race (check all that apply)

American Indian Asian Pacific Islander White Black Hispanic Non-Hispanic

Participant’s LEGAL Custodial Parents/Guardians

#1 – Full Name:

Home Address: Email Address: Cell/Home Number:

#2 – Full Name:

Home Address: Email Address: Cell/Home Number:

Emergency Contact if above individuals are unavailable

Full Name: Relationship to participant:

Cell/Home Phone:

Participant’s Family Physician

Name: Address:

Phone

Medical and Dietary Restrictions (list all known and reaction management):

YES NO YES NO Had any recent injury, illness, or infectious disease? Ever had high blood pressure?

Have a chronic or recurring illness/condition? Ever been diagnosed with a heart murmur?

Ever been hospitalized? Ever had back problems?

Ever had surgery? Ever had problems with joints, knees, or ankles?

Have frequent headaches? Have an orthodontic appliance brought to camp?

Ever been knocked unconscious? Have any skin problems (rash, acne)?

Wear glasses, contacts, or protective eyewear? If female, any abnormal menstrual history?

Ever had frequent ear infections? Had problems with diarrhea or constipation?

Ever passed out, dizzy, or chest pain during exercise? Had mononucleosis in the past 12 months?

Ever had an eating disorder? Have diabetes?

Had problems with sleepwalking? Have asthma?

Ever had seizures? Have a history of bed wetting?

Ever had emotional difficulties? Have severe allergies?

Carry an epi-pen or inhaler?

Explanation of YES answers:

Behavior or Medical History

Are there any other behavior needs, accommodations, or information which the staff should be made aware of to provide a better

camp experience for the participant?

Immunization Records

Is the camp participant up-to-date on immunizations as outlined by Kentucky law required for enrollment in public or private school,

based upon the grade the participant will be enrolled for the upcoming school year?

YES

NO (If marked NO, check with your 4-H agent for a waiver of liability form.)

Does the participant have health insurance coverage? YES (Attach a copy – front and back – of the insurance card in the boxes below.)

NO (No worries! Camp provides an excess medical insurance coverage in the event of injuries or illnesses.)

FRONT OF INSURANCE CARD BACK OF INSURANCE CARD

Do you want to buy your camper/teen some camp gear? www.4hcampstore.com

Is your camper looking for more camping opportunities? www.4hcampevents.com

CAMP USE ONLY (Healthcare Staff Review Stamp)

CAMP PARTICIPANT’S NAME: _________________________________________________________________________

AUTHORIZATIONS/RELEASES This is a legal document. You must read and understand it before signing it.

Consent to Treat:

The health history reported on page one and two are correct and complete to the best of my knowledge. The person herein described has permission

to engage in all camp activities except as noted. I hereby permit the camp to provide routine health care, administer over the counter medication,

assist in administering participant’s prescription medications as needed, and seek emergency medical treatment including ordering x-rays and routine

tests. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I permit the camp to arrange necessary

related transportation for my child. In the event I cannot be reached in an emergency, I hereby permit the physician selected by the camp to secure

and administer treatment, including trips out of camp.

Media Release:

I grant the Kentucky 4-H Program and the University of Kentucky, and persons acting through them, the right to use, reproduce, assign, and/or

distribute photographs, films, videotapes, and sound recordings of my minor child without compensation for use in promotion/advertising,

educational publications, electronic publishing, and personal memorabilia. Participant names may be published.

Yes. I grant permission for media releases. No. I do not grant permission for media releases.

Code of Conduct:

I have read and discussed the Code of Conduct with my participant. We (parent/guardian and participant) understand and agree to comply with the

guidelines. Violations may result in the loss of privileges, removal from camp with no refund, assessment of a damage fee I will be responsible for

paying, and/or ineligibility to participate in future 4-H events. An incident report will be completed for major violations

Permission to Participate:

I understand that my child’s participation in the Kentucky 4-H Summer Camping Program is based on the challenge by choice philosophy. I

recognize that programs are designed to use experiential, engaging teaching techniques, but that my child’s participation is purely voluntary, always,

and my child will choose his or her level of participation in any activity. The camp activities listed below require acknowledgement of the risks

involved and permission to participant from the parent/guardian. Place a check indicating YES or NO next to each activity, and then sign below.

YES NO YES NO

High Ropes Horses (WKY only)

Low Ropes Cave (LC only)

Archery

Firearms

Pick-up Release:

It is my responsibility to arrange to pick up my child/children upon return from camp. There will be no exceptions to this policy regardless of

relationship to the child. Please inform everyone approved by you on this release that he/she must present a driver’s license or photo ID before the

child will be released. Parents, Guardians, and Emergency Contacts listed on page 1 are automatically assumed to have pick up

authorization. In addition to the parents/guardians listed on page 1, the following individuals are granted permission to pick up my child

NAME: __________________________ RELATIONSHIP________________________________ Phone/Cell# ______________________

NAME: __________________________ RELATIONSHIP________________________________ Phone/Cell# ______________________

NAME: __________________________ RELATIONSHIP________________________________ Phone/Cell# ______________________

Assumption of Risk and Release of Liability:

I acknowledge that there are certain risks, hazards, and dangers, including the risk of physical injury, disability, or death and risk of loss of use or

damage to my personal property as a result of allowing participation in the camping program. Risks include but are not limited to recreational games

and traditional camp activities, transportation accidents, weather-related hazards and natural disasters, infectious diseases, the possibility of slips and

falls, pinches, scrapes, twists, and jolts that could result in scratches, bruises, sprains, lacerations, fractures, concussions, or even more severely

debilitating or life-threatening hazards. I understand that injury or loss may result from unknown or unexpected risks and the use of equipment,

materials, or facilities recommended by the University of Kentucky; environmental conditions; from the acts or omissions of others; or from the

unavailability of immediate and adequate emergency medical care. I understand that the University of Kentucky does not guarantee the personal

health or safety of participants, nor does it protect against the risk of loss of personal property. In consideration for allowing my child to participate in

the camping program, I do hereby release Kentucky 4-H Camp, the University of Kentucky, and its members, trustees, officers, employees,

independent contractors, volunteers and extension staff from any and all liability, damages, cost, and expenses arising out of or relating to bodily or

psychological injury, loss of life, or personal property that may occur as a result of participating in the camping program.

Participant Signature: ____________________________________________________ Date: _______________________

Parent/Guardian Signature: ____________________________________________________ Date: _______________________

Payment

Camper Name: _________________________________

Payment Enclosed: __________

Payment Type:

__ Check __ Money Order

*Entire Registration fee must be submitted with application

packet unless applying for a scholarship.

Special Cabin Leader Request: Cabin Leader requests are limited to

one per camper. My child would like to have this cabin leader (Adult or Teen)

in their cabin (List ONLY one name): ________________________________________________

This is a request only - We will do our best to honor, but it is not guaranteed!

Parent Checklist

_____ Completed Camper Application with parent and child signatures, and designated pickup individuals listed.

____ Copy of insurance card (front and back)

Special Requests Cabin mate requests are limited to

one camper per camper.

My child would like to be cabin mates with (list ONLY one name):

__________________________________________________

This is a request only - We will do our best to honor, but it is not guaranteed!

*To help ensure your camper is assigned to a cabin with a special request camper, mail applications and payments

together - otherwise, all efforts will be made to make these placements, but are not guaranteed.

Be Sure to Enclose this form

in with your complete 4-H

Camp Application.

We look forward to seeing you at 4-H

Summer Camp. It is going to be Out of this

World!!!