Reply to: Cooperative Extension Service Fayette County 1140 Harry Sykes Way Lexington, KY 40504-1383 (859) 257-5582 Fax: (859)254-3697 Fayette.ca.uky.edu

Date: January 2020 To: Prospective 4-H Camp Junior Counselor (JC) From: Kevin Lindsay Madalyn Wells County Extension Agents for 4-H Youth Development RE: 2020 4-H Summer Camp Greetings! This application is for teens wishing to be a Junior Counselor (JC) for Fayette County 4-H camp. Age for JC’s are youth age 16 to 19.

The 2020 camp week will be with Franklin County 4-H. Location: J.M. Feltner 4-H Camp; London, KY Date: Monday, June 15 - Friday, June 19, 2020 To be considered for this leadership position, your completed application packet must be received by March 31, 2020. Any applications received after the March 31st deadline will be addressed on a case-by-case basis pending the need for additional JC’s. Due to the rising cost of camp, ALL JUNIOR COUNSELORS ARE REQUIRED TO PAY $78.00 FOR CAMP. All JC applicants will be interviewed this year, so your completed application packet must be submitted by the DEADLINE of March 31, 2020. The attached application contains the following items: camp registration form, application checklist, statement of understanding, applicant information page, position description, and recommendation form. You are also required to submit a current color photo of yourself with your application. Incomplete applications will be returned so that they can be corrected by the applicant. Y ou will not be interviewed for camp until all application paperwork and the fee have been received. If accepted as a JC, you will be required to attend the face-to-face training listed below and the camper orientation. YOU MUST ATTEND THE FACE-TO-FACE TRAINING AND CAMPER ORIENTATION TO GO TO CAMP!! Orientation: Monday, June 1st 6-9 pm Fayette County Extension Office AND Training: Saturday, June 6th 9 am - 4 pm Franklin County Extension Office 101 Lakeview Court, Frankfort KY

To be considered for a Junior Counselor interview, you will need to submit the following by March 31

st.

- Camp Registration Form - Signed Information Page/Volunteer Agreement - Recent Color Photo - Signed Position Description - Signed Statement of Understanding - Recommendation Form (Do not use relatives.) - $78.00 payment (check or money order) Thank you in advance for applying to become a 4-H camp JC for 2020. If you have any questions, please contact us by email (kevin.lindsay@uky.edu or madalyn.wells@uky.edu) or by telephone at (859) 257-5582.

Kentucky 4-H Camping 2020

Camp Participant Registration – Camper/Teen

Last Name:

Legal First Name: Middle Name: Preferred Name:

Attended camp before?

❑ Yes - # years: ___

❑ No

Fall 2020 School & Grade: County: Gender Identity:

❑ Male

❑ Female

Shirt Size: (Select One)

YS YM YL YXL AS AM AL AXL A2XL A3XL A4XL

Birthdate:

______ / ______ / ______

Age on 1st day of camp?

Participant’s Home Address:

Participant’s Race:

❑ White

❑ Black

❑ Asian

❑ American Indian

❑ Hawaiian

❑ Other

Participant’s Ethnicity:

❑ Hispanic

❑ Non-Hispanic

Legal Parent/Guardian #1 Full Name:

Email Address: Cell/Home Number:

Legal Parent/Guardian #2 Full Name:

Email Address: Cell/Home Number:

Emergency Contact Full Name:

Relationship to Participant: Cell/Home Number:

Physician Name:

Physician Phone Number:

Buy your participant some camp gear. www.4hcampstore.com

Is your participant looking for more camp opportunities? www.4hcampevents.com

http://www.4hcampstore.com/http://www.4hcampevents.com/

What is specific information about your camp participant which the staff should be made aware of to provide a better camp experience

for the camp participant? Are there specific items that the participant is provided at home or school to have a successful experience?

Behavioral (i.e., mental, emotional, physical)

Medical (i.e., asthma, autism, sleepwalker, braces, glasses)

Dietary (i.e., gluten intolerant, sensitive to dairy, picky eater)

Other accommodations or important details:

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

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. Use tape, DO NOT staple.)

❑ NO (No worries! The camp provides excess medical insurance coverage in the event of injuries or illnesses.)

FRONT OF INSURANCE CARD BACK OF INSURANCE CARD

PARTICIPANT NAME: ____________________________________________________

PARTICIPANT NAME: _______________________________________________________________________________

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

MEDIA RELEASE:

I grant the Kentucky 4-H Program and the University of Kentucky, Kentucky State University, 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.

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 and 2 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# ______________________

CONSENT TO TREAT:

The health history reported on page one and two are correct and complete to the best of my knowledge. 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 off camp property.

CODE OF CONDUCT:

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

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

ASSUMPTION OF RISK, RELEASE OF LIABILITY, and PERMISSION TO PARTICIPATE:

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, Kentucky State University, 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. 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 (including, but not limited to: high ropes, rock climbing, low challenge elements,

rifles, archery, trap shooting, horses, and cave exploration).

Participant Signature: ____________________________________________________ Date: _______________________

Parent/Guardian Signature: ____________________________________________________ Date: _______________________

Fayette County 4-H Camp Teen Counselor Application Checklist

(Eligible: Youth, ages 16 - 19 years old *)

Please return this checklist with your application.

____ 2020 Summer 4-H Camp Participant Registration Form, Copy of Insurance Card (front & back), form

signed by JC and parent/guardian

____ Recent color photo of applicant (please attach below)

____ Junior Counselor Statement of Understanding signed by child and parent/guardian

____ Junior Counselor Information Page/Volunteer Agreement signed by child and parent/guardian

____ Camp Junior Counselor Position Description signed by child and parent/guardian

____ Camp Counselor Recommendation Form (Do not use relatives or Fayette County 4-H Staff members.)

____ Camp Fee of $78.00 (Check or Money Order payable to Fayette Co 4-H Council)

Application Received: ____________________

*If applicant is 18 or 19 years old, a Volunteer Application packet must be submitted with the JC application. Please contact KevinLindsay or Madalyn Wells by email (kevin.lindsay@uky.edu or madalyn.wells@uky.edu) or by telephone(859-257-5582) to have aVolunteer Application packet sent to you.

FOR OFFICE USE ONLY:

Interview Date & Time: ____________________________________________

*Completed Volunteer Application Packet: YES NO

Verified By: ______________________________________________

*Clear Background Check: YES NO

Verified By: ______________________________________________

Completed Summer 2020 4-H Camp Application: YES NO

Verified By: _____________________________________________

Online Camp Training Successfully Completed: YES NO

Verified By: _____________________________________________

Confirmed Attendance of face to face training: YES NO

Verified By: _____________________________________________

*Required only if applicant is 18 or 19 years old.

Attach

Color

Photo

Here

Fayette County 4-H Camp Junior Counselor Statement of Understanding

By signing below, I am stating that I understand the following items and/or requirements:

1. If am chosen as a Junior Counselor, the attendance of many campers is solely dependent upon my attendance. In the event that my availability changes, I will immediately notify a 4-H Agent.

2. I am required to attend an interview where I will be asked questions regarding my experience in camping and programming with youth. Counselors that have previously attended 4-H Summer Camp will also be asked to provide feedback on their experiences.

3. I am required to complete the online leader trainings by the date set forth by the 4-H Agents.

4. I am required to attend the face-to-face training listed below and camper orientation. I understand I will not be permitted to attend camp without attending the face to face training and camper orientation.

Camper Orientation: Monday, June 1st 6-9 pm Fayette County Extension Office AND Training: Saturday, June 6th 9 am - 4 pm Franklin County Extension Office 101 Lakeview Court, Frankfort KY __________________________________________________ ________________

Junior Counselor Applicant Signature Date

__________________________________________________ ________________

Applicant Parent/Guardian Signature Date

1. Are you willing to assist with classes? ____Yes ____No If yes, please indicate area(s) of interest below.

2. How do you feel you could help with these classes? (Be specific)

3. List any 4-H activities (including camp) that you have been involved in over the past year:

5. What abilities and/or personal strengths do you have that you can use as a Camp Counselor?

Junior Counselor (Teen) Volunteer Agreement Form

By signing this document, I understand that I will be expected to complete leader trainings (BOTH online and face to face)

prior to the stated deadlines. I also agree to abide by the University of Kentucky’s 4-H Camper/Counselor Responsibilities

(enclosed in this application packet) and I understand I could be dismissed from camp and not allowed to return in the future

for inappropriate behavior.

JC Signature: _____________________________________________________________ Date: _________________

Parent/Guardian Signature: _________________________________________________ Date: _________________

Fayette County Junior Counselor Information Page

Applicant’s Name: ______________________________________________________________________________

Years at camp:_______________ Years in 4-H:______________

E-mail address:________________________________________________________________________________

Cell Phone:___________________________________________________________________________________

Permission to receive/send text messages? _____ Yes _____ No

Did you attend the 4-H Camp Recruitment Fair held at the Fayette County Extension Office on January 17, 2020?

_____ Yes _____ No

VOLUNTEER POSITION DESCRIPTION Kentucky 4-H/Youth Development Program; Fayette County The University of Kentucky Cooperative Extension Service

POSITION TITLE: 4-H Camp Junior Counselor (Teen Leader)

TIME REQUIRED: Training and Camp Orientation prior to camp Camp: Five (5) days/ (4) evenings

LOCATION: 4-H Camp Ground located at: J.M. Feltner 4-H CampFace-to-Face Training: Franklin County Extension Service OfficeCamper Orientation at: Fayette County Cooperative Extension Service Office

GENERAL PURPOSE: + Supervision of 12-16 youth, ages 9-15, in a camping setting+ Support 4-H professionals, volunteers and members in conducting meaningful educational experiences to help youthdevelop social skills

SPECIFIC RESPONSIBILITIES: + Along with the adult leader, reside in a cabin with campers. A teen leader must never be alone with campers while inthe cabin. An adult must always be present when in the cabin.+ Under the direction of the adult leader in your cabin, supervise group living environment (i.e. housekeeping, personalhygiene, social skills, responsibility, sharing, following rules, discipline campers).+ Assist with bus loading and unloading+ Provide leadership and direction while working closely with adult leaders and agents.+ Follow all guidelines and policies of the University of Kentucky and 4-H programs+ Assist in orienting campers to the camp and program.+ Stay with cabin members at all times, unless permission is granted by camp director.+ Help take care of campers’ personal property.+ Help create positive attitude of campers in cabin.+ Have a “quiet” cabin after lights are out.+ Assist adult leaders, permanent staff and agents, upon request, with special activities such as quiet time, flag raising/lowering, keeping camp ground clean, etc.+ See that campers carry out responsibilities such as cabin cleanup, grounds cleanup, dining hall cleanup, etc.+ Check health and safety needs of campers. Watch for fatigue in camp group.+ Be on the alert for homesickness or other issues+ Encourage and involve camper participation in camp activities+ Assist campers in making choices in classes/activities.+ Make sure campers are on time for programs.+ Encourage campers to try new activities.+ Actively participate in implementing the camp’s programs.+ Assist class instructors where needed in teaching or in managing campers’ behavior.+ Assist campers during class periods.+ Assist in rainy day programs by supervising games in cabin, etc.

HR-6

4-H CAMP POSITIONCamp Junior Counselor

+ Assist with program planning and evaluation.+ Assist Staff, Adults, and Agents in managing emergency events, e.g. severe weather, tornado warning, missingcamper. Specific tasks will be assigned.+ Report daily on progress, situation, problems and successes to County Extension Agents and attend Staff meetings asrequested.+ Project a positive and enthusiastic attitude about camp which campers may model.+ Report any problems to your adult counselor, Dean of Men/Women or your county 4-H Agent.+ All leaders are ultimately responsible to the Camp Program Director for the camp in which they are involved.

QUALIFICATIONS: + Must be 16 - 19 years old at time of camp+ A sincere interest in youth development+ Ability to work and communicate effectively+ Willingness to follow rules+ Ability to get along with others+ Positive attitude+ Ability to follow instructions at camp, especially during an emergency situation+ Completed camp and health forms; including the required Tetanus vaccination+ If 18 or 19 years old, must undergo the Kentucky 4-H volunteer application and screening process and be acceptedas a volunteer.

BENEFITS: + Developing positive relationships with campers, adult counselors and CES staff+ Seeing youth develop and gain skills+ Appropriate training, teamwork and support+ Opportunity to share in an exciting week of activities with youth+ Chance to share ideas with other adult and teen leaders

SALARY: Unsalaried; Volunteer. Fees for Junior Counselors: $78.00 Transportation provided

MENTOR/SUPERVISING PROFESSIONALS:

Kevin Lindsay Madalyn Wells

Fayette County Extension Agents for 4-H Youth Development

1140 Harry Sykes Way, Lexington, KY 40504

Phone: (859) 257-5582

Email: kevin.lindsay@uky.edu / madalyn.wells@uky.edu

______________________________________________________ ______________

JC Signature Date

______________________________________________________ ______________

Parent/Guardian Signature Date

______________________________________________________ ______________

4-H Agent Signature Date

Fayette County 4-H Camp Junior Counselor Recommendation Form

Do not use relatives or Fayette County 4-H Staff members.

Name of Applicant: ________________________________________________________________________________

I am interested in being a counselor at 4-H Camp this summer. The County Extension Agents for 4-H Youth Development would like your input about my qualifications to fulfill the responsibilities of a camp counselor. Please comment on the following topics and return this form to the address listed below by March 31st. Thank you.

Kevin Lindsay Fayette County Cooperative Extension 1140 Harry Sykes Way Lexington, KY 40504

How would you rate the applicants? Above Average Average Below Average Emotional maturity/judgment _____ _____ _____ Leadership Abilities _____ _____ _____ Flexibility _____ _____ _____ Communication skills _____ _____ _____ Enthusiasm and energy _____ _____ _____ Self confidence _____ _____ _____ Respect for authority _____ _____ _____ Completion of tasks _____ _____ _____ Working with youth _____ _____ _____ Responsibility _____ _____ _____

Have you seen this applicant in a leadership position? If yes, please explain in what capacity.

Please describe this applicant’s ability to work with others on a team.

Why would you recommend this applicant to be a 4-H Camp Junior Counselor? (be specific)

Additional comments:

_______________________________ ________________________ _____________________ Printed Name Signature Date

Relationship to applicant: ______________________________ Email: ___________________________________

Please return to the Fayette County Cooperative Extension Office by March 31, 2020.

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