dear parents and campers! - university of maryland · welcome to the 2019 4-h pre-teen xtreme camp!...

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Dear Parents and Campers!

Welcome to the 2019 4-H Pre-Teen Xtreme Camp! This year’s camp will take place at Camp Round Meadow Catoction Mountain in Thurmont, Maryland and will be held from August 12 - 16, 2019.

You already know that camp presents a tremendous opportunity for your child to broaden horizons, make new and lasting friends, and discover new strengths. After all, you wouldn’t be considering camp if you didn’t think it would add substantially to your child’s growth and development. Although camp can help your child learn leadership, team-building, make healthy lifestyle, eating and physically choices, and improve a skill in just about any physical endeavor, the true payoff of camp will be apparent when your child comes home more self-reliant, self-sufficient, and self-confident. What a gift to give to your child!

We know that you are sending your most cherished loved ones to camp with us and we hope that you don’t think it’s strange of us to ask you to take some time to write down a few things that you would want us to know about your child. Oh sure, there are those official camp forms where you tell us what your son or daughter is allergic to, physical description and if they’re immunizations are current, but we also want to know who they are as a person and their interest. We want the campers’ stay to be a life time memory as it was for many of the staff that went to camp as a child.

Our first priority is to create a safe, inclusive space for learning, sharing, and collaboration welcoming to people from diverse backgrounds, cultures and perspectives. Campers this year will participate in activities centered on an International Day theme. They will have the opportunity to learn facts about different countries and create a cultural dish.

The campers will also be participating in the usual camp activities of swimming, hiking, arts & crafts, good fun and of course the Thursday night dance. We will keep the campers moving all week with a variety of activities.

We are an accredited camp through the American Camping Association (ACA). This is verification from the ACA that our camp has complied with up to 300 industry-established health and safety standards, which are recognized by courts of law and government regulators as the standards of the camp industry. In 2001 our camp won the Eleanor P. Eells Award from the ACA for program excellence. We were nominated for this award again for our 2002 camp and placed in the top five in the country.

Attached is a final list of items campers need to bring with them to camp. Emergency contact information for the camp ground is as follows: Catoctin Mountain Park (6602 Foxville Road Thurmont, MD 21788-2598)

Should you have any further questions or concerns, please feel free to contact Ariel Delgado 301-868-9636.

Thank you and we look forward to seeing you at camp!

Lenora HarperLenora Harper Camp Director

The University of Maryland Extension programs are open to all citizens without regard to race, color, sex, handicap, religion, age, national origin.

The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e. sign language interpreter, support, etc.)

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4-H CAMP PACKING INFORMATION

Welcome to the 4-H Xtreme Teen Camping Trip! Your participation in all scheduled programs, contributions to sessions, and friendly attitude will make this an exceptional four and a half day experience. You will meet new people, explore new ideas, share your interests, and speak out on issues that matter to you.

Who, When and Where? The camp will take place at the Camp Round Meadow-Catoctin Mountain Park, 14840 Manahan Rd, Sabillasville, Maryland, from August 12 - 16, 2019. Youth between the ages of 9-13 (as of Jan. 1, 2019) are allowed to participate.

Transportation A bus will be picking up and dropping off camp participants from Seat Pleasant Activity Center. Please have someone bring and pick up from this location. You will not be allowed to leave your personal vehicle on the premises.

DirectionsWe’ll be using a commercial bus. From Washington DC take the 495 north to I270 north 27 miles to Frederick, MD. Take Route 15 17 miles north to Thurmont, MD. Take Route 77 West, the exit sign is marked Catoctin Mountain Park. Travel approximately 6 miles west on 77 (you will pass Park Central Road and the park Visitor Center) and turn right onto Foxville-Deerfield Road. As the road forks, turn right onto Manahan Road. Continue approximately 3/4 mile and turn left into Camp Round Meadow. Park in the large gravel parking lot.

When You Arrive at Seat Pleasant Activity CenterParents/Guardian must check you in at the registration area before boarding the bus. All Medications must be turned in at the registration area. It is important to arrive on time because we will be leaving Seat Pleasant Activity Center at 8:00 a.m. SHARP!

The University of Maryland Extension programs are open to all citizens without regard to race, color, sex, handicap, religion, age, national origin. The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program

start date to request accommodation (i.e. sign language interpreter, support, etc.)



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Cabin Living Camp gives you a chance to experience all aspects of outdoor living. Camp participants will be housed with eight teens and two counselors. This is a great chance to get to know teens from other areas. Cabin changes cannot be granted during camp. While you are at camp remember that you represent yourself, your community and family. Treat all property with respect. Males and females are housed separately and teens are not permitted to visit the rooms of opposite sex participants. We will have cabin meetings at night to answer any questions about the next day and to help you solve any problems you may have encountered.

Special Needs If you have any needs which require modifications in housing, meals, or program, please contact Ariel Delgado by Friday July 19, 2019 with your requests so that appropriate accommodations can be made.

What to Bring A checklist for camp is attached to this letter. Leave items of value at home. The program is not responsible for items lost during camp. Dress for camp is fun wear. You will need to bring bed linens, towels, and personal care items. Please be sure that everything you bring to camp is clearly marked with your name.

What Not To Bring to Camp Weapons (knives, guns, etc.) No food No Sandals

Special Events tentatively scheduled for this year’s camp trip:

Field Day International Day Talent Show

REQUIREMENTS

Must be a teen between the ages of 9-13 (as of Jan. 1, 2019) Must be registered in 4-H Online



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Questions-If you need additional information about camp please contact Ariel Delgado 301-868-9636.

Medication (if applicable) (please make sure appropriate forms are completed and signed)

Bring comfortable outfits

Sleepwear

One piece swimwear (ONLY)

Towel(s) (lake and shower) & Washcloth(s)

Shower shoes or flip flops

Closed toe/Comfortable walking shoes

Light jacket/sweater

Sleeping bag/bed linen

Pillow

Personal items (toothbrush/paste, deodorant, soap/shower gel, sunscreen, etc.)

No! electronics of any kind: cell phone, ipod/ipad,

tablet, MP3/dvd/cd players, gaming systems

Packing Checklist:

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Drop-off and Pick-up Location:

Seat Pleasant Activity Center

5720 Addison Rd.

Seat Pleasant, Maryland 20743

(301) 773-6685Drop-off: Monday, August 12, 2019 @ 7:30 am

Pick-up: Friday, August 16, 2019 @ 2:30 pm



TALENT

SHOW

2019

G E T R E A D Y T O S H I N E !

AUGUST 15, 2019

If you have a talent you would like toshowcase, be sure to sign-up once at camp!



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FEES and CHARGES

Total Camp Fee per camper (Ages 9-13) $150.00.

Payment Deadline: Friday, July 19, 2019. All paperwork must be completed and accompany the youth prior tocamp. Any youth that does not have all required paperwork completed WILL NOT be allowed to go to camp – NOEXCEPTION!

DETAILS:

Only Cash and Money Orders will be accepted! NO CHECKS WILL BE ACCEPTED

Please make money order payable to: Prince George’s County Extension Advisory Council - PGCEAC

CANCELLATION AND REFUNDS:

A two (2) week cancellation notice is required! Cancellation and refund request on both partial and fully paid registrations are subject to a $25.00 cancellation fee per person. NO EXCEPTIONS!

For more information, please call Ariel Delgado at 301.868.9636 or via email ([email protected])

REGISTRATION FORM

Camper’s Name: ____________________________________ Age: ______ DOB: ____________

Parents/Guardian’s Full Name: _________________________________________________________

Street Address: ___________________________________________________________________

City: ________________________________ State: _________ Zip Code: ____________

Work Phone: _________________________ Home Phone: ______________________

Circle and list Information Dietary / Disability / Health Concern

I have read all information started I this brochure from camp management and I agree to all the terms stated above.

_________________________________ ________________________________________ Parents/Guardian Signature Date

Mail Registration Payment to: University of Maryland Extension

Attn: Ariel Delgado6707 Groveton Drive Clinton, MD 20735

Completed Registration Forms may be emailed to:[email protected]

Registration Packet



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Maryland 4-H Behavioral Expectations

A goal of the Maryland 4-H program is to provide opportunities for children and youth to build character. Maryland 4-H supports the CHARACTER COUNTS!SM six pillars of character: TRUSTWORTHINESS, RESPECT, RESPONSIBILITY, FAIRNESS, CARING AND CITIZENSHIP. In order to ensure that Maryland 4-H programs provide positive environments for all individuals to learn and grow, 4-H participants agree to abide by these expectations of behavior: (CHARACTER COUNTS! Is aservice mark of the CHARACTER COUNTS! Coalition, a project of the Josephson Institute of Ethics.)

I will be trustworthy. I will be worthy of trust, honor and confidence. I will be a model of integrity by doing the right thing even when the cost I high. I will be honest in all my activities. I will keep my commitments by attending all sessions of the planned event. If I am not feeling well or have a schedule conflict, I will inform my chaperon or a person in charge. I will be in the assigned area (e.g., club meeting room, building, and dorm) at all times. Maryland 4-H does not permit dishonesty by lying, cheating, deception or omission.

I will be respectful. I will show respect, courtesy, and consideration to everyone, including myself, other program participants and those in authority. I will act and speak respectfully. I will treat program areas, lodging areas, and transportation vehicles with respect. I will not use vulgar or abusive language or cause physical harm. I will appreciate diversity in skill, gender, ethnicity and ability. Maryland 4-H does not tolerate statements or acts of discrimination or prejudice.

I will be responsible. I will be responsible, accountable and self-disciplined in the pursuit of excellence. I will live up to high expectations so I can be proud of my work and conduct. I will be on time to all program events. I will be accountable by accepting responsibility for my choices and actions. I will abide by the established program curfew. I will be responsible for any damage, theft or misconduct in which I participate.

I will be fair. I will be just, fair and open. I will participate in events fairly by following the rules, not taking advantage of others and not asking for special exceptions.

I will be caring. I will be caring in my relationships with others. I will be kind and show compassion for others. I will treat others the way I want to be treated. I will show appreciation for the efforts of others. I will help members in my group to have a good experience by striving to include all participants.

I will be a good citizen. I will be a contributing and law-abiding citizen. I will be respectful to the environment and contribute to the greater good. I will not use any illegal substances such as tobacco, alcohol and drugs.

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Maryland 4-H Disciplinary Policy and Procedures

I. Maryland 4-H expects youth participating in programs to behave in an acceptable manner and in accordance withthe Maryland 4-H Behavioral Expectations outlined on the reverse side of this document. 4-H participants whoengage in unacceptable conduct, including the following behaviors, are subject to discipline.

• Possession, use, or distribution of alcohol and/or illegal drugs.• Possession or use of weapons or dangerous materials.• Possession or use of tobacco products.• Misuse of prescription or nonprescription drugs.• Sexual activity.• Lying, cheating, and misrepresenting project work or other unethical practices.• Unauthorized absence from program site.• Physical, verbal, emotional, or mental abuse of, or threats toward another person.• Theft, destruction, or abuse of property.

II. A participant in a 4-H program who engages in conduct (including the above behaviors) that, in the discretion ofthe extension faculty, staff or MCE volunteer in charge, may jeopardize the health or safety of the participant orothers, or the integrity of 4-H, will be dismissed immediately from the program (meeting, activity, event, trip,camp, etc.). The participant’s parent or guardian will be responsible for providing transportation home for a childif dismissed.

III. Following a program, a participant and his/her parent or guardian will be notified in writing of the nature of anyunacceptable conduct for which sanctions (up to and including suspension from one or more 4-H programs ordismissal from (4-H) are being considered. In such cases:

• The extension faculty or staff member with overall responsibility for the program will set up a meeting to hearthe 4-H member. The 4-H member’s parent or guardian will be permitted to be present at such time. At the discretionof MCE or at the request of the 4-H participant, a committee may be appointed by MCE to review the matter.• Following the meeting, the 4-H participant and his or her parent/guardian will be notified in writing of theoutcome of the meeting and any sanction(s) to be imposed.• Sanctions may be appealed in writing within seven (7) days after receiving notice of the decision, to theCounty Extension Director (CED). In the event that the extension faculty in charge also serves as the CED, theappeal will be made to the Regional Extension Director (RED).• The 4-H participant and his/her parent or guardian will be notified in writing of the decision of the CED (orRED). The decision of the CED (or RED) may be appealed in writing to the State 4-H Leader within seven (7) daysafter receiving notice of the decision. The decision of the State 4-H Leader will be final.

“I HAVE READ THE MARYLAND 4-H BEHAVIORAL EXPECTATIONS AND THE MARYLAND 4-H DISCIPLINARY POLICY AND PROCEDURES. I AM AWARE THAT MY ACTIONS AND DECISIONS AFFECT ME AND OTHERS AND MAY RESULT IN LOSS OF PRIVILEGES DURING 4-H PROGRAMS, AND FOR FUTURE PROGRAMS. I WILL ACCEPT THE APPROPRIATE AND LOGICAL CONSEQUENCES OF MY ACTIONS, AS DETERMINED BY MARYLAND 4-H.”

Member Signature _____________________________________________________________________________ Date __________________________

“AS THE PARENT/GUARDIAN OF ________________________________________________, I HAVE READ THE MARYLAND 4-H BEHAVIORAL EXPECTATIONS AND THE MARYLAND 4-H DISCIPLINARY POLICY AND PROCEDURES AND WILL SUPPORT THE INDIVIDUAL IN CHARGE IN MAINTAINING APPROPRIATE BEHAVIOR. I AGREE TO ACCEPT THE APPROPRIATE AND LOGICAL CONSEQUESNCES OF MY CHILD’S ACTIONS AS DETERMINED BY MARYLAND 4-H.”

Parent/Guardian Signature ___________________________________________________________________ Date _____________________________

“It is the policy of the University of Maryland, Agricultural Experiment Station and Maryland Cooperative Extension, that no person shall be subjected to discrimination on the grounds of race, color, gender, religion, national origin, sexual orientation, age, marital or parental status or

disability.”



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UNIVERSITY OF MARYLAND UNIVERSITY OF MARYLAND EXTENSION

PARENTAL RELEASE AND INFORMED CONSENT FORM PROGRAM: 4-H Pre-Teen Xtreme Camp DATE(S): August 12-16, 2019

My minor child, as listed below, has my permission to fully participate as a representative of the University of Maryland Extension (UME) Maryland 4-H Youth Development Program in all activities associated with the above named program.

In connection with and consideration of my child’s participation in the Program, I, on behalf of my child and myself, my heirs, personal representative(s) and assigns, hereby represent and agree as follows:

1. I am aware that any program related activity can be dangerous, and I fully recognize and understand that there are risksand hazards, both minor and serious, associated with participation in the Program and related activities, including, butnot limited to: cuts, scrapes, bruises, broken bones, muscle strains, pulls or tears, head, neck, back, eye and other bodilyinjuries, heat prostration, brain damage, blindness, deafness, drowning, heart attacks, paralysis and, even, death. Thefollowing is a description and examples of specific, significant, non-obvious dangers and risks associated with thisactivity. There is potential for accidents and/or injuries arising from: (Add the activities here – see sample for suggestions)a. Transportation to and from camp (Camp Round Meadow – Thurmont, MD)b. General camping activitiesc. Hikingd. Swimming

2. I understand that my child is not in any way required to participate in the Program, but I want them to participate, despitethe possible dangers and despite this Release.

3. I represent and warrant that my child has no physical, health related or other problems which would preclude or restricttheir participation in the Program or otherwise render their participation dangerous or harmful to them or others. Ifurther represent and warrant that my child has adequate medical, health and/or other insurance for participation.

4. Knowing the dangers, hazards and risks associated with the Program, and with sufficient knowledge of my child’sphysical condition(s) and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage, illnessand/or injury to person or property which my child may, in any way, sustain in connection with participation in theProgram and related activities.

5. I agree that my child must abide by all rules and regulations applicable to participation in the Program. Should my childrequire emergency medical treatment or first aid as a result illness or injury associated with the Program or relatedactivities, I consent to such first aid and/or treatment.

6. To the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and to indemnify andhold harmless, the State of Maryland, the University of Maryland, University of Maryland Extension and their governingboards, officers, agents, employees and volunteers from and against any and all liabilities, claims, demands and causes ofaction of any kind on account of any loss, damage, illness or injury to person or property in any way arising out of orrelating to my child’s participation in the Program and/or related activities, whether due to the negligence, mistake or other action or inaction ofUME or any other person or entity.

7. I do hereby consent and agree that the Maryland 4-H Youth Development Program has the right to take photographs or record video/audio tapes ofmy child and to use these for educational and/or promotional materials. I further consent that my child's name may be revealed therein or bydescriptive text or community. I hereby release to the Maryland 4-H Youth Development Program all rights to exhibit this work publicly orprivately, including posting it on the Maryland 4-H Website. I waive any rights, claims or interests I or my child may have to control the use of mychild's identity or likeness in the photographs, video or audio, and agree that any uses described herein may be made without compensation oradditional consideration of me or my child.

I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ AND FULLY UNDERSTAND THIS RELEASE AND INFORMED CONSENT FORM, AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Signature of Parent/Guardian Having Care and Custody of Participating Child Date

Name of Parent/Guardian: Emergency Telephone: ( )

Participating Child’s Name: Signature: Age:

University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or parental status, or national origin. Rev. - July 2000 (D. Andrews) Updated for Extension Name and Logo Change AMT 3/2010

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PHOTOGRAPH RELEASE FORM

Prince George’s County 4-H Camping Program

During 4-H Camp at Camp Round Meadow; camp staff, directors, and counselors take photographs of the children involved in various activities throughout the week. These photos may be used on the Prince George’s County 4-H website, camp website, in the 4-H newsletters, and brochures.

Initial one of the following:

______ I grant permission _______ I do not grant permission

for my child’s photographs from the 2019 4-H Camp to be used in Prince George’s County 4-H publications. I understand granting permission will allow the general public to view these photos.

I do hereby release, discharge and hold harmless and indemnify the University of Maryland Extension, University of Maryland System, and State of Maryland, and all regents, officers, employees, agents, successors and assigns thereof, from any and all claims and demands of whatever nature, actions, causes of action appeals, obligations, liabilities, promises, suits, rights, charges, damages, punitive damages, cost, loss of service, loss of employment opportunity, emotional suffering, cost of litigation, humiliation, embarrassment, mutual anguish, injury of reputation, personal injury, and any and all other legal, equitable or administrative relief of any kind, known or unknown, suspected or unsuspected, having already resulted or to result in the future, as a result of or relating to my participation in the above program and/or activity.

I, the undersigned, acknowledge that I sign this Release knowing and intelligently and with full and complete knowledge of the purpose of said program and without any form of duress and/or intimidation whatsoever on the part of the University of Maryland Extension, or University of Maryland System.

Parent/Guardian Signature: ______________________________ Date: ___________

Child’s Name: ______________________________

The University of Maryland Extension programs are open to all citizens without regard to race, color, sex, handicap, religion, age, national origin. The Department of Parks and Recreation encourages and supports the participation of individual with disabilities. Please contact the facility at least two weeks in advance of the program start date to request accommodation (i.e.

sign language interpreter, support, etc.)

University of Maryland Extension Prince George’s County

6707 Groveton Drive Clinton, MD 20735

301-868-9636 (phone)301-599-6714 (fax)

MARYLAND 4-H CAMPS Sunscreen Authorization Form

Dear Parents:

The Maryland Department of Health and Mental Hygiene has adopted a policy regarding the use of sunscreen at youth camps. In order to operate a camp in the state of Maryland, we must abide by the policy as outlined below.

Please read the following regarding use and application of sunscreen at Maryland 4-H Camps. The authorization statement must be completed and submitted along with sunscreen labeled for your camper (one form and bottle per camper) on the first day of camp, at the start of each subsequent week, if the brand of sunscreen changes, or if a new bottle is supplied at any time.

Please address questions about this policy to your Camp Coordinator.

MARYLAND 4-H CAMPS SUNSCREEN POLICY 1. Each Camper’s parent/guardian must provide written permission for use and application of sunscreen on their child.2. Sunscreen containers must be clearly labeled with the Camper’s name and must be provided to Camp Staff at camp check-in.

This signed authorization form must submitted along with the sunscreen.3. Campers should, in most instances, apply the sunscreen on their own. If assistance is needed it will be provided by Camp

Staff ONLY if specifically authorized (see below).4. For Day Camps, Campers need to have sunscreen applied to them by the parent/guardian BEFORE arriving at camp, not

when dropping off.

MARYLAND 4-H CAMPS SUNSCREEN AUTHORIZATION (Complete and sign appropriate block below)

Camper’s Name: ________________________________________________ Camper’s Age: _______________

Brand of Sunscreen: ________________________________ SPF: ____________ Expiration Date: ______________

I give permission for members of the Maryland 4-H Camp Staff to assist in applying sunscreen to my child. I understand that this may require the staff member to touch my child’s face, shoulders, back, arms, and lower legs. Sunscreen will be applied in the presence of other staff members. I understand that staff will not apply sunscreen to my child’s front torso or upper legs, but will assist and/or direct the child to do so.

In the event my child does not bring sunscreen to camp and conditions warrant its use, by my signature below I authorize members of the Maryland 4-H Camp Staff to use camp supplies of sunscreen, and to apply this sunscreen to my child’s body as described above.

___________________________________________ Parent/Guardian’s Printed Name

___________________________________________ Parent/Guardian’s Signature

__________________ Date

OR

I DO NOT give permission for Maryland 4-H Camp Staff Members to assist in applying sunscreen to my child.

___________________________________________ Parent/Guardian’s Printed Name

___________________________________________ Parent/Guardian’s Signature

__________________ Date

University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression.

4/2015

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1. The 4-H Online login page is shown at right.

2. To set up a family profile, select “I need to setup a profile.”

3. Make sure Role is set to “Family” and that County is set to

“Prince George's.”

4. Enter your family/household’s last name, the main email

address for the household, and a password for your family

account. PLEASE DO NOT LOSE your password or forget

which email you used! You will need them both to re-enroll

as a member every year and to select your projects.

5. Click Create Login.

6. You will see the Family Information page.

a. You can return to this page in the future to update

your family’s information.

b. You will need to complete anything with a red star

next to it.

c. If you click Update member records with the same

address, all individual 4-H members in your family will

automatically be assigned the same mailing address.

Individual addresses can be changed later.

d. Skip the Password Management section since you

already created a password. You can come back to

this section later to change your password.

e. In the future, if you forget your family’s password, go

to the 4-H Online login page and select “I forgot my

password.” A new password will automatically be emailed to your main email

address.

f. Click Continue.

Youth Enrollment 4-HOnline - Prince George's County (please complete on-line enrollment prior to camp)**If you already have an account please inform Ariel Delgado ([email protected]), $10 participation fee does not need to be paid**

4-H Online—Enrolling New Youth Members & Adult Volunteers in 4-H

The 4-H Online system is used to enroll and re-enroll youth members and adult volunteers in 4-H. You will also use it to manage your online 4-H profile, which is where

you will choose the clubs you want to join and the 4-H projects you want to enroll in. In the future, it may also be used to register for certain 4-H activities and events. The

link to 4-H Online can be found on Montgomery County’s Join 4-H page (https://extension.umd.edu/montgomery-county/4-h-youth/join-4-h) or the Members page

(https://extension.umd.edu/montgomery-county/4-h-youth/4-h-member-area).

There are two types of accounts in 4-H Online—family/household accounts and individual accounts. A family/household account must be created first. Then, individual

members create accounts for themselves within their family/household account.

How to Create a Family/Household Account

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https://extension.umd.edu/montgomery-county/4-h-youth/join-4-h

https://extension.umd.edu/montgomery-county/4-h-youth/4-h-member-area

The University of Maryland, College of Agriculture and Natural Resources programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental

disability, religion, ancestry, or national origin, marital status, genetic information, political affiliation, or gender identity and expression.

How to Create an Individual Member Account 7. Member List page (shown at right)

a. This page is used to manage the accounts of anyone in your family. You can

also click Edit Family to change the info you entered on the previous page.

b. In the middle of the screen you will see a section listing all 4-H members in

your family.

c. Where it says Add a New Family Member, select “Youth” or “Adult” and click

Add Member. Parents SHOULD NOT create individual member accounts for

themselves unless they are also 4-H volunteers.

8. Personal Information page

a. Please make certain to fill out ALL the boxes. It is VERY IMPORTANT for

youth to include parent names and contact information. There is also a

section to be filled out if the member lives in more than one home.

b. If you have a different last name or email than your family, they can be

changed here.

c. Make certain to correctly fill out the Years in 4-H box. If you are a new

member, it should say 1, not 0.

9. Additional Information page

a. By logging in with your user ID and password, you are indicating that you are

the correct person to agree to the terms.

b. Read the 4-H Behavioral Expectations and sign it.

c. Complete the Photo Release. Check “Yes” or “No” and sign. Click Continue.

d. If you carry an animal project, read and sign the Code of Animal Science

Ethics.

10. Health Form page

a. This page is optional, but is required to participate in certain events. Click

Continue.

11. Add a Club page

a. Select the club you want to join and click Add Club. If you choose more than one club, you must select one to be your primary club. Click Continue.

12. Add a Project page

a. You can come back to this page in the future if you haven’t spoken to a club leader yet about which 4-H projects you should take. Every 4-H member must be enrolled

in at least one project. You don’t need to select any project materials. To select a project, first select the club you will take it in, then the project you want to take, then

click Add Project, and then Submit Enrollment.

13. Once your enrollment has been submitted, you may log out. You will shortly receive an email confirmation of your enrollment with information regarding payment of the

$10 enrollment fee. You may pay online or pay your club leader. If you’re paying by check and you belong to more than one club, make sure you make your payment to your

primary club. Clovers and adult volunteers don’t pay a fee, and only the first three youth members in a family pay it.

12 **Please note if this is not completed prior to camp your child may not be able to participate. If you already have a profile please be sure that is is active/up to date. If you have any questions or concerns please contact the office at (301) 868-9636.**

Cell Phone Statement

At 4-H Pre-Teens Camp, we have always had a “no cell phone” policy. Due to potential liabilities, enforcement of this policy is crucial to our continued camp success. Aside from the fact that cell phones are expensive and

can get lost or stolen and that the physical camp environment is not kind to such items, there is a fundamental

problem with campers having cell phones at camp, and that is trust. When children come to camp they–and

you-are making a leap of faith, transferring their primary care from you as their parents to us and their

counselors. This is one of the growth-producing, yet challenging aspects of camp. As children learn to trust

other caring adults, they grow and learn, little by little, to solve some of their own challenges. We believe this

emerging independence is one of the greatest benefits of camp. It is one important way your children learn to

become resilient. Contacting you by phone essentially means they have not made this transition. It prevents us

from getting to problems that may arise and addressing them quickly. Sending a cell phone to camp is like

saying to your child that you as the parent haven’t truly come to peace with the notion of them being in our care.

You can help by talking with your child before they leave for camp and telling them that there is always

someone they can reach out to; whether it is a counselor, a trusted activity leader, the head counselor or even the

director. We are here to help, but if you don’t trust us, they certainly won’t.

It is important to understand why cell phones are not only disruptive but can lead to other situations. Cell

phones that are cameras can be used to take pictures in cabins that might accidentally catch another camper

indisposed. That picture can then be sent out via picture mail, posted to Facebook, etc. That is not a situation

that the camper, their parents or us as a camp staff want to happen. This is just one of the possible situations that

can occur if you allow your child to bring a cell phone to camp.

Any cell phone that is brought to camp will be collected and held until the end of the week and WILL BE

RETURNED TO A PARENT/GUARDIAN at pick-up. Disciplinary action may be taken depending on the

circumstances.

I, _______________________________, have read the above information and agree not to bring a cell phone to

camp. I understand that if I am seen with a cell phone during any part of my time at camp, it will be collected

and held until the end of the week. This could affect whether or not I will be asked to participate in camp the

following year as a leader.

________________________________ ____________________________________

Signature of Camper Signature of Parent/Guardian

***your child will not be permitted to board the bus unless this form is signed and on file with camp staff***

The University of Maryland, College of Agriculture and Natural Resources programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national origin, marital status, genetic information, political affiliation, or gender identity and expression.

14

MARYLAND 4-H CAMPS HEALTH FORM

Current Photo

Of Camper

Camper’s Name: __________________________________________________________________________ Last First MI Nickname

Male Female

Age at Camp Arrival: ______ Birthdate: ________________

MM/DD/YYYY

Dates will attend Camp: ______________ to _______________ MM/DD/YYYY MM/DD/YYYY

Home Address: _________________________________________________________________________ Street Address _________________________________________________________________________ City State ZIP County

School Attended: __________________________________________________________________________ County: ___________________ Private Public Other _________________________ School Address: _________________________________________________________________________

Street Address City State ZIP

PARENT/GUARDIAN To be Notified in case of Injury or Illness: Name:___________________________ Relationship: _____________________ Preferred #1 __________________________

Phones: #2 __________________________ Indicate mobile (M), home (H), work (W) E-mail: ___________________________________________________________________

Home Address: if different from camper

_________________________________________________________________________________________________ Street Address City State ZIP

SECOND PARENT/GUARDIAN Or other Emergency Contact: Name:___________________________ Relationship: _____________________ Preferred #1 ________________________

Phones: #2 ________________________ Indicate mobile (M), home (H), work (W) E-mail: _____________________________________________________________

ADDITIONAL CONTACT in event parent(s)/guardian(s) cannot be reached: Name:___________________________ Relationship: _____________________ Preferred #1 ________________________

Phones: #2 ________________________ Indicate mobile (M), home (H), work (W) E-mail: _____________________________________________________________

HEALTH CARE PROVIDER CONTACTS Name: Phone:

Primary Care Physician: ______________________________________________ ________________________________ Dentist: ______________________________________________ ________________________________ Orthodontist: ______________________________________________ ________________________________ Other Provider (Specify): _____________________ ______________________________________________ ________________________________

HEALTH INSURANCE: Is camper covered by health/medical insurance? Yes No Insurance Company: _______________________________________________ Phone Number: __________________________________ Policyholder’s Name: _______________________________________________ Policy Number: __________________________________

Attach photocopy of insurance card; be sure to copy both sides of card so information is readable

CAMPER HEALTH SUMMARY (Camp Use - See additional pages for detailed health history)

Camper has mild/moderate allergies Camper has severe allergies that require immediate medical

attention: __________________________________________ Camper carries an Epi-pen, inhaler, or other emergency device:

__________________________________________________

Camper takes daily medication Camper has dietary needs or restrictions Camper has physical limitations or disability Camper has personal issues/needs:_________________________________________________________

University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry or national origin, marital status, genetic information, political affiliation, or gender identity and expression. 4/2016

CAMPER HEALTH HISTORY Page 2 Camper’s Name: ___________________________________ Age: ___________ Birthdate: _______________________

IMMUNIZATION CERTIFICATION: State in which camper resides/attends school: ______________________________________Date of last Tetanus immunization: __________________________________

Is camper exempt from any immunizations? Yes No List: ___________________________________________________

I certify my child has received and is up-to-date on all immunizations required for school attendance in the state where s/he lives/attends. If my child has not received required immunizations, I certify the appropriate exemptions or exceptions have been recorded with my child’s school. I understand and accept the risks of my child not being fully immunized per state requirements.

Signature of Parent/Guardian: ______________________________________ Date: ____________

Relationship to Camper: _________________________

GENERAL HEALTH HISTORY: Check “Yes” or “No” for each statement. Explain “yes” answers in space below.Has/does the camper:

1. Ever been hospitalized? Yes No 12. Had fainting or dizziness Yes No 2. Ever had surgery? Yes No 13. Passed out/had chest pain during exercise? Yes No 3. Have a recurrent/chronic illness? Yes No 14. Had mononucleosis (mono) in the last month? Yes No 4. Had a recent infectious disease? Yes No 15. If female, had problems with period/menstruation? Yes No 5. Had a recent injury? Yes No 16. Have problems with falling asleep or sleepwalking? Yes No 6. Had a recent head injury or concussion? Yes No 17. Ever had back/joint problems? Yes No 7. Had asthma/wheezing/shortness of breath? Yes No 18. Have a history of bedwetting? Yes No 8. Have diabetes? Yes No 19. Have problems with diarrhea or constipation? Yes No 9. Had seizures? Yes No 20. Have any skin problems? Yes No 10. Had headaches? Yes No 21. Traveled outside the country in the past 9 months? Yes No 11. Wear contact lenses, glasses, or protective eyewear? Yes No 22. Have any other condition or issue not listed? Yes No Explain “yes” answers in the space below, noting the question number. For travel outside the country, list countries visited and dates of travel.

ALLERGIES: No known allergies Allergic to: Foods Medicines Environment Other (Circle all that apply & describe below. Attach additional pages if necessary)

What is camper allergic to? (Specific) What is the typical reaction seen? What is treatment is needed?

DIET/NUTRITION: Eats regular diet Eats regular vegetarian diet

Lactose intolerant Glucose intolerant

Other (Please explain below)

Notes about camper’s diet/nutrition:

MENTAL, EMOTIONAL, AND SOCIAL HEALTH: Check “yes” or “no” for each statement.Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)? YES NO2. Ever been treated for emotional or behavioral difficulties or an eating disorder? YES NO3. In the past 12 months, seen a professional to address mental/emotional health concerns? YES NO4. Had a significant life event that continues to affect the camper’s life?

(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, etc) YES NO5. Is this the camper’s first time away from home/family for an overnight event? YES NOPlease explain “yes” answers in the space below, noting the number of the question. Attach additional pages if needed. The camp may contact you for additional information.


CAMPER HEALTH HISTORY Page 3 & AUTHORIZATION

Camper’s Name: ___________________________________ Age: ___________ Birthdate: _______________________

ADDITIONAL INFORMATION:

Please provide any additional information about the camper’s health or well-being you think may be important for staff to know or that may affect the camper’s ability to fully participate in the camp program. Attach additional pages if needed.

RESTRICTIONS: I have reviewed the program and activities of the camp and feel the Camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the Camper can participate with the following

restrictions or adaptations (please describe):

AUTHORIZATION FOR PARTICIPATION, TREATMENT, AND RELEASE OF LIABILITY I certify that this health history is correct and accurately reflects the health status of the camper to whom it pertains. I hereby give permission for medical personnel selected by University of Maryland Extension (UME) to provide routine health care; to order x-rays, and routine tests; to administer medications, injections, anesthesia, surgery, and other treatment; to release records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission for medical personnel selected by UME to secure and administer treatment including hospitalization for the participant named above. I further understand that I will be responsible for medical/hospital bills. By signing this form, I give permission for the participant named above to participate in all program activities except as specified herein. This completed form may be copied for trips out of camp and/or away from the program site. By signing this form, I release and forever discharge, agree not to sue, and to indemnify and hold harmless the State of Maryland, University of Maryland, and University of Maryland Extension and/or their officers, agents, employees, faculty, staff, and volunteers from and against any and all liabilities, costs, expenses, causes of action, claims, and/or demands in any way relating to the foregoing program activities and/or the health, illness, injury, and/or treatment of the participant named above.

Signature of Parent/Guardian: ________________________________________ Date: _____________

Relationship to Camper: __________________________

Signature of Adult Camp Participant: _____________________________________ (over 18 years of age)

Date: _____________


CAMPER MEDICATIONS Page 4 Camper’s Name: ___________________________________ Age: ___________ Birthdate: _______________________

“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. Campers who will take daily medications, vitamins, supplements, etc. while attending this 4-H Camping Program must complete the Medication Administration Authorization Form, which must be signed by BOTH the Camper’s Parent/Guardian and the prescribing Physician. Campers who will take daily medications must bring their own supply of prescription or non-prescription medications, and the supply must be provided by an adult to the Camp Staff upon arrival. See the Medication Administration Authorization Form for further details and instructions.

Check the applicable statement below:

Camper WILL NOT bring/take daily medication(s), vitamins, or supplements while attending camp.Camper WILL bring/take daily medication(s), vitamins, or supplements while attending camp.*

*Medication Administration Authorization Form is required

CAMP HEALTH CENTER MEDICATIONS & REMEDIES

The Camp will stock certain non-prescription medications and remedies in the Camp Health Center that may be used on a one-time or limited as-needed basis to manage minor illness and injury. Dosages of these medications and remedies will be administered according to directions on the label unless the Camper’s Parent/Guardian provides written direction provided for alternate dosage or use. Check the boxes below to select which medications/remedies from the Camp Health Center you authorize the Camp Staff to administer to your Camper, according to general labeling instructions. Note any alternate use/dosage directions in the comments below, specifying EXACTLY which medication/remedy may be used other than as directed, and how it may be used for your Camper.

Acetaminophen (i.e. Tylenol) Antihistamine/allergy medicine Aspirin Ibuprofin (i.e. Motrin, Advil) Pseudoephedrine decongestant (i.e. Sudafed) Cough drops Naproxen/NSAID (i.e. Aleve) Guaifenesin cough syrup (i.e. Robitussin) Antibiotic cream Pepto-Bismol (for upset stomach/diarrhea) Sore throat spray Insect repellent/Bug Spray Immodium (for diarrhea) Diphenhydramine antihistamine/allergy

medicine (i.e. Benadryl) Aloe gel or cream (for sunburn)

Laxative (for constipation – i.e. Ex-Lax) Calamine Lotion

Comments:

I give permission for UME-designated Camp Health Supervisor/Monitor to administer the medications and remedies listed above. I understand the medications/remedies maintained at the Camp Health Center are only for one-time or limited-time use, and will not be provided to my Camper on a long-term or continuing basis. I understand the medications/remedies will be administered according to label directions unless I specifically directed otherwise in the “Comments” section above.


Relationship to Camper: ____________________________



MEDICATION ADMINISTRATION AUTHORIZATION FORM MARYLAND 4-H CAMPS

This form must be FULLY completed and signed by both the Camper’s Parent/Guardian and Physician for Camp Staff members to administer the required medication, or for the Camper to self-administer medication. A new Medication Administration Authorization Form must be completed at the beginning of each camp season, or any time there is a change in dosage, use, or administration of a medication. Unless updated sooner, this form is valid for one year from the date of Physician’s signature. All medications or substances authorized by this form must be handled as follows:

• Prescription medications must be in original pharmacy container, labeled with the Camper’s name, name of medication, dosage,frequency of administration, prescription number, and prescribing physician’s name and phone number. Medication label informationmust match the information and instructions provided on this form.

• Non-prescription medications, vitamins, and supplements must be in original container with instructions for use on label.• Containers must contain exactly enough medication for Camper’s use during scheduled duration of the Camp (NO “extras”)• An adult must bring the medication to Camp and give the medications to an adult staff member. Multiple medication containers for

one Camper should be collected in a clear plastic bag labeled with the Camper’s name.• Campers who are authorized to self-carry/self-administer medication (such as inhaler, insulin, Epi-pen, etc) may carry the

medication to Camp but must, in the presence of a responsible adult, show it to an adult Camp Staff member when checking in

CAMPER TAKES THE FOLLOWING MEDICATIONS ON A DAILY OR ROUTINE AS-NEEDED BASIS: (Include all prescription medications and non-prescription medications, vitamins, supplements, etc. supplied by the Camper)

Name of Medication

Dates Taken Reason for Taking

Times Taken & Dosage

Route (oral, topical, etc)

Special Instructions/Side effects *Note if Emergency Medication

Can Camper Self-Administer?

(see reverse for policy)

*Copy this page if more space is needed. Physician must sign EACH PAGE listing medications.

Physician’s Signature

Physician’s Name/Title

Physician’s Phone Date Signed Physician’s Address Stamp

OVER – Additional Signatures Required on Reverse



PARENT/GUARDIAN AUTHORIZATION

I request the authorized Camp Staff to administer medication or supervise the Camper in self-administration if authorized, as prescribed by the Physician. I certify that I have legal authority to consent to medical treatment for the Camper named above, including the authority to consent to administration of medication. I understand that my camper should bring EXACTLY the amount each medication required for the duration of the Camp, in properly-labeled containers. However, further I understand that if any medication remains at the end of the authorized period it must be picked up by an adult, otherwise it will be discarded. I authorize Camp personnel to communicate with the prescriber as allowed by HIPAA.



AUTHORIZATION FOR SELF-ADMINISTRATION / SELF-CARRY MEDICATIONS

This section should be completed if medication is approved for self-administration and/or self-carry by the Camper under supervision of a Camp Staff member. “Self-administration” means the Camper is able to take/apply the medication without assistance, but under supervision of a Camp Staff member. “Self-carry” means the Camper may carry the medication with him/her during Camp activities. Self-carry of medication by Campers is permitted only for emergency medications such as inhalers, insulin, epinephrine, etc. Unless noted as “self-carry,” all self-administered medications will remain under control of Camp Staff designee and dispensed according to the listed schedule.

All self-administered and self-carry medication must be listed on the reverse of this form. Both the Physician and the Parent/Guardian must consent to self-administration and/or self-carry by the Camper. However, Maryland youth camp operators are not required to permit self-administration or self-carry by Campers.

I consent that the Camper named above is able to self-administer the medication(s) as listed on the reverse of this form. I authorize self-administration of the listed medication(s) by the Camper under the supervision of an authorized Camp Staff member. If indicated below, the Camper may self-carry emergency medication and self-administer as necessary.

Emergency medication(s) authorized for SELF-CARRY by Camper (must also be listed on reverse of this form):



Physician’s Signature

Physician’s Name/Title

Physician’s Phone Date Signed Physician’s Address Stamp


dear parents and campers! - university of maryland · welcome to the 2019 4-h pre-teen xtreme camp!...

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