(Last) (First)

This form must be completed for each club!

Name: _________________________________________________________________

Address: (Street) _________________________________________________________

(City, Zip) _______________________________________________________

School: ____________________________________

Grade: _________ Check One): Male Female

Birth Date: _____/_____/_____ Age (as of Jan. 1, 2017): ________

Primary Phone: __________________ Youth Cell Phone (opt.): __________________

May we text the cell phone numbers provided for youth and adults? Please circle one: (YES) (NO)

Name Parent /Guardian #1: _______________________ Cell Phone: _____________

Name Parent /Guardian #2: _______________________ Cell Phone: _____________

Parent / Family Email Address: ____________________________________________ (4-H information, updates, and reminders are sent by email)

Where do you live?: (Check One): Farm Rural (not on farm) Town

(Check One): White Hispanic Black Asian American Indian

Club / Project Name:

4-H MEMBER

(Youth ages 9-18 as of Jan. 1, 2016)

2016-2017 Enrollment Form

Today’s Date:

HEATHER CASSILL and RACHEL NOBLE

Clark County Extension Agents for 4-H Youth Development 1400 Fortune Drive

Winchester, KY 40391 (859)744-4682

Facebook: Clark County 4-H (KY)

SHOOTING SPORTS

Remind System: Text @4hhotshots to 81010 to stay updated!

4-H Participant Information/Enrollment Form (NOT FOR RESIDENTIAL CAMP)

Note: The form must be completed by the participant and/or parent or guardian in order to participate in the 4-H program. All items must be completed, even if the response is not applicable – indicate by using N/A (i.e. no health insurance). Failure to complete this form in its entirety will result in the person being ineligible to participate in 4-H activities. Please print in blue or black ink to allow for photocopying.

Name: County/District: Last First

Address: Birth date: Age: Youth Female

Adult Male

City: State: KY Zip: Email: Home Phone: Farm: ☐ Yes ☐ No

Race: ❑Asian ❑White ❑Black ❑American Indian ❑Hawaiian & Pacific Islander ❑Hispanic ❑Non-Hispanic Grade:

Emergency Contact #1: Phone H W C Phone H W C

Emergency Contact #2: Phone H W C Phone H W C

Name of Family Doctor: Doctor’s Phone:

Health Insurance Company: Policy #:

Name of Policy Holder/Relationship to Participant: Member ID:

HEALTH HISTORY

Does the participant have, or at any time has had, any of the following? Check “Yes” or “No” to each item. Please explain any “yes” answers (noting the number of the item) in the space below or on an additional sheet if necessary. Reporting conditions will not prevent a person from attending and will be kept confidential.

Yes No 1) Asthma ………………………………

2) Bronchitis………………………………

3) Convulsions……………………………..

4) Diabetes…………………………………

5) Ear Infection…………………………….

6) Fainting………………………………….

7) Heart Condition…………………………

8) Headaches………………………………

9) Hypoglycemia…………………………...

10) Serious Allergy to Insects…………...…

11) Wear Glasses/Contacts………………

12) Other Conditions………………………

13) Drug Allergy (please explain) ………

14) Food Allergy (please explain) ………

15) Other Allergy (please explain) ……….

Please Explain Any “Yes” Responses:

List and explain any restrictions (dietary, physical, etc):

The following over the counter medications may be administered to my child without contacting me:

Antihistamine Pill Antacid Ibuprofen (Advil) Hydrocortisone Cream

Acetaminophen (Tylenol) Decongestant Dramamine Polysporin (topical antibiotic)

MEDICAL TREATMENT All information provided on this form is correct and complete to the best of my knowledge. This person has permission to engage in all events and activities. I hereby give permission to the event designee to provide routine health care, administer prescription and over the counter medications as noted and seek emergency medical treatment if warranted. I agree to the release of all records necessary for medical treatment, billing or insurance. In the event I cannot be reached in an emergency, I give permission to the attending physician to secure and administer treatment, including hospitalization. SIGNATURE OF PARENT/PARTICIPANT: DATE:

PUBLICITYRELEASE

I hereby grant the 4-H program, University of Kentucky and their agents, the right to use, reproduce, assign and/or distribute still pictures, video and sound recordings of myself or my minor child without compensation for use in promotion, advertising, educational publications or online content.

SIGNATURE OF PARENT: NO, I do not permit.

Revised 10/4/13

4-H Youth Development CODE OF CONDUCT FORM (NOT FOR RES IDENTIAL CAMPS)

All 4-H members and family/friends associated with 4-H members must respect the individual rights, safety, and property of others and adhere to this Code of Conduct. The following guidelines are designed to make your experience at 4-H events safe, meaningful and satisfying to you and all others attending.

WHILE ATTENDING ALL 4-H MEETINGS, PROJECTS, PROGRAMS, ACTIVITIES AND EVENTS: • Each 4-H participant is expected to attend all planned sessions, workshops, field trips, and meetings of the event, and to be

in appropriate dress. Dress codes will be specific to individual events. Delegation chaperones and/or volunteers are

responsible for ensuring that members participate in all aspects of the planned program activities.

• The possession and use of alcoholic beverages, tobacco products, and/or drugs (except for medications prescribed to the

participant by a licensed physician) are strictly prohibited. Delegation chaperones and/or volunteers shall limit use of tobacco

products to designated areas.

• Setting off fire alarms, tampering with fire extinguishing and other emergency equipment are strictly prohibited.

• Gambling of any type is strictly prohibited.

• Obscene, discriminatory and/or inappropriate language, roughhousing, and insubordination are prohibited at all times.

• Respect toward others and facilities shall be demonstrated. Bullying, harassment of others or destruction of property shall

not be tolerated. Bullying and harassment can include the use of social media.

• Display of overly affectionate or inappropriate attention between participants is strictly prohibited.

• Technological equipment (including but not limited to cell phones, laptops or mp3 players) shall not interfere with the program

and may not be allowed in certain situations.

• Each county may adopt additional Code of Conduct guidelines.

WHILE ATTENDING OVERNIGHT CONFERENCES, CAMPS, AND EVENTS, THE FOLLOWING WILL ALSO APPLY:

• All participants are to be in their assigned area at curfew and comply with quiet hours, lights out, and other rules of the event.

• No member or volunteer may leave the grounds without the permission of the conference director or adult in charge. An adult

shall accompany a 4-H member any time he/she leave the grounds. Adults shall notify another adult in the delegation before

leaving the grounds.

• At overnight events, only Conference participants may be in sleeping areas. Lounges or common areas may be used only

for working committees and social activities.

• Room service such as phone calls, food, laundry, or others shall not be permitted without chaperone permission.

Any violations of this Code of Conduct shall be reported promptly to the adult in charge of the delegation/program and to the person in charge of the event. The person in charge of the event shall have the final responsibility for disciplinary action. Failure to comply with the Code of Conduct by 4-H’ers and family/friends associated with the 4-H participant may result in penalty, including, but not limited to, the following:

• Sent home from the activity or event at his/her own expense

• Barred from participation from future 4-H events

• Assessed the cost of damages for destruction of property

• Released to nearest law enforcement authority

• Termination of 4-H membership

I, , have read the Code of Conduct and agree to abide by its rules. (Print Name)

I understand that infraction of this Code of Conduct will result in any or all of the penalties listed above.

Member/Volunteer County

Parent/Guardian Date

Clark County 4-H Shooting Sports

4-Her’s Name:

Discipline (can choose more than one): □ Archery □ Rifle □ Shotgun □ Air Rifle/BB

4-Her’s Signature: Date: Parent’s Signature: Date:

2016

RULES FOR PARTICIPATION

CLARK COUNTY 4-H SHOOTING SPORTS PROGRAM

1. All participants must complete the Hunter Safety Education Course.

2. All equipment is to be brought to the sight of practice unloaded, (firearms with action open, arrows in

quiver, clear barrel indicator in place), and enclosed in some type of casing.

3. All equipment and ammunition must be approved by the corresponding leaders of that discipline.

4. All equipment is to remain unloaded and in cases until members are instructed otherwise by the

leaders.

5. NO horseplay of any kind will be tolerated.

6. All leader directions must be followed. When attention of group is called for, members must listen

and follow leader’s specific instructions. Full attention is expected while coaches are speaking. NO

rudeness will be tolerated.

7. All members must provide their own safety equipment and must wear it at all times when on the

firing line. This includes hearing and eye protection for rifle and shotgun, eye protection for BB guns

and finger and forearm protection with archery.

8. A parent, guardian, or someone authorized by the parent or guardian must be present during each

meeting. (No one is to drop off and leave a child.)

9. Fees for participation may be required.

10. If the audience or spectators of practice are disruptive to the operations of the practice the

individual(s) and 4-Her they accompany may be asked to leave.

11. I have personally reviewed the Risk Management Plan and shared this information with my child.

12. I understand that the Clark County Extension Annex Building indoor range is strictly for youth

participant use only and any misuse of the property will result in the 4-H Shooting Sports Club paying for

damages and no future use of facility.

13. I understand that Education programs of Kentucky Cooperative Extension serve all people regardless

of race, color, age, sex, religion, disability or national origin. University of Kentucky, Kentucky State

University, U.S. Department of Agriculture, and Kentucky Counties, Cooperating. Disabilities

accommodated with prior notification.

I understand that it is my responsibility to review and explain these rules to my child. I certify by

signing this form that we both understand and plan to abide by these rules. We understand that

consequences may incur if these rules are broken. I do grant my permission for my child to

participate in the Kentucky and Clark County 4-H Shooting Sports program.

_________________________________

Parent Signature 4-H Member Signature

CLARK COUNTY 4-H

SHOOTING SPORTS CLUB

WAIVER OF LIABILITY

I, , as legal guardian of

understand that my child has enrolled in the 4-H Shooting Sports Program. I understand that this

program uses equipment such as shotguns, rifles, BB guns, and archery gear. I understand that

accidental injuries can occur in the use of this equipment.

I agree not to hold any of the following parties responsible in the event of accidental

injury or death:

University of Kentucky

University of Kentucky College of Agriculture Food and Environment

Cooperative Extension Service or any of its employees

United State Department of Agriculture

Clark County Extension Council or any officer and member

Clark County District Board or any officer or member

Clark County 4-H Council or any officer or member

Kentucky and National 4-H Programs

4-H Volunteer Leaders for Youth Development

4-H Extension Youth Development Agent

Any private property owner

Clark County Fish and Game Club

Central Kentucky Coon Hunter’s Association

Guardian’s Signature: ___________________________________ Date:

FOR PARENT’S INFORMATION

CLARK COUNTY 4-H

SHOOTING SPORTS CLUB

RISK MANAGEMENT PLAN

(Revised February 2014)

ALL EFFORTS SHALL BE MADE TO ESTABLISH A SAFE ENVIRONMENT FOR

MEMBERS USING THE FOLLOWING PROCEDURES.

1. The EMS, fire department, and a physician will be notified one time at the beginning of

the year of the dates of all club or specific discipline meetings.

2. A first-aid kit will be at the site of every regular or special meeting.

3. A cellular phone will be activated for every regular of special meeting.

4. Current medical release forms will be accessible at all regular and special meetings.

5. Accident insurance will be purchased for every member and volunteer leader.

6. Additional liability insurance may be purchased for every certified coach and adult range

assistant.

7. Eye and ear safety equipment will be mandatory for every member and leader on or near

the firing line.

8. The firing line will be clearly marked in plain sight on a safely constructed range.

9. Range officers will be present at every regular or special meeting and are responsible for

checking all equipment as well as enforcing safety procedures for shooters.

10. Safety rules will be reviewed before range sessions.

11. Adults and selected Teens will be trained as discipline coaches by the KY Shooting

Sports Program.

12. Only individuals who are registered as 4-H Shooting Sports Club Members are allowed

to participate in club activities. To be a member in good standing all participation,

insurance, code of conduct, enrollment and waiver forms must be completed and on file

at the Clark County Extension Office.