4-H Memorial Camp. Please use a separate registration for each camper or if you are attending multiple camp weeks. Camper Information

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1 4-H Memorial Camp 2018 Summer Camp Registration Please use a separate registration for each camper or if you are attending multiple camp weeks. Camper Information Camper s First Name Male Female Camper s Last Name Age of Camper during camp session: Are you a currently enrolled H member? Yes No If your County cannot verify your 4-H enrollment status, your camp registration will be placed on-hold and could be voided. If you aren t sure about your current 4-H enrollment status, please contact your local Extension Office or 4-H Club leader, prior to registering for camp. Please select your home County How many years (including this year) have you attended 4-H Camp? My Bunk Mate Choice is: You may list one, same-gender bunk mate of comparable age We make every attempt to accommodate bunk mate requests, however, it is not always possible Parent/Guardian Information Parent/Guardian First Name Parent/Guardian Last Name Parent/Guardian Street Address City State Zip Code Best Contact Day Phone Best Contact Evening Phone IMPORTANT! Parent/Guardian Address: Note: This will be used for your confirmation, your packing list and any other information that prepares you for camp. In case of an emergency, if we cannot contact you, please provide an alternate contact Alternate Contact First Name Alternate Contact Last Name Relationship to Camper Alternate Contact Phone Number I want to attend this 4-H Camp Week: Select Week Dates Camp 1 June 3-7, 2018 Camp 2 June 10 - June 14, 2018 Camp 3 June 17 - June 21, 2018 Camp 4 July 1 - July 4, 2018 (2:00 p.m., Sunday 3:00 p.m., Wednesday) (Check one. Multiple Sessions require separate registration forms) Camper Registration is $235 per camper Currently enrolled 4-H Members receive a discounted registration: $195 for registrations made from January 16 - March 31, 2018 Registrations by check must be post-marked by 3/31/18 $215 for registration made starting April 1, 2018 Camper check-in office use only Cabin number Overall feeling Recent illness (within last 10 days) Current medications Special dietary needs The 4-H Camp is a place that does not allow the following items brought to camp: knives (even pocket knives), alcohol/tobacco, firearms or cell phones iid you bring any of these items with you today? Page 2 of registration form complete and with parent signature? Person conducting interview Page 1 of 5

2 Parental Consent I give permission for my child to participate in all camp activities including swimming, boating, climbing, team challenge course, shooting sports and out of camp travel into adjacent Robert Allerton Park when it is part of the camp program. I understand my child will be informed of the Illinois 4-H behavior guidelines and 4-H Camp Code of Conduct which stress a demonstration of the character traits of trustworthiness, respect, responsibility, fairness, caring, and citizenship. Should a child display a blatant disregard for these rules, I will be notified and agree to pick up my child from the camp program. I grant 4-H Memorial Camp irrevocable permission to record and/or disclose my child s identity, image, and voice arising out of documenting 4-H Memorial Camp programming and to use, reproduce and distribute such in whole or in part in video and/or sound recordings, films, photographs, transparencies, webpages, social media, local news media or any other media for any purpose on behalf of the University of Illinois and University of Illinois Extension without compensation to me and without any right for me to inspect or approve of the finished photograph, video, or audio recordings or other recordings. Parent/Guardian First Name Parent/Guardian Last Name Parent/Guardian Signature Date (A handwritten signature is mandatory. We cannot accept an electronic signature) Your completed 5-Page Registration Form Must be Received by 4-H Memorial Camp within TEN Business Days Mail to: 4-H Memorial Camp, 499 Old Timber Rd. Monticello, IL OR Fax to: OR to: 4hmemorialcamp@illinois.edu If you have questions, please call us at Cancellation Policy Central Illinois Camping Association Refund Policy: $150 of fee refundable if cancellation is 7 days or more prior to camping session No refund when the cancellation is made 6 days or less prior to the first day of camping session CHECKLIST: Stop! io you have everything? Completed and signed Registration Form? Completed and signed Health Form? Completed and signed Waiver? Page 2 of 5

3 Confidential 4-H CAMP HEALTH HISTORY This form must be completed for each child by the parent/guardian and returned to 4-H Memorial Camp information will be kept confidential for the child s welfare. Camp Week Camper s First Name Camper s Last Name Male Female Date of Birth Parent/Guardian First Name Parent/Guardian Last Name Parent/Guardian Street Address City State Zipcode Best Contact Day Phone Best Contact Evening Phone ALL medications, prescription and non-prescription, MUST be in the original container in which they were issued (with medical orders and physician's name intact), and given to the nurse/health director during camp session. Check Over-the-Counter Medications That Your Child May Receive if Deemed Necessary: Antiseptics Diarrhea medication Antibiotic Ointment Benadryl Non aspirin pain medication Is this camper current on immunizations required to attend school in Illinois? YES NO If no, please explain Last Booster: Tetanus Check Below if Your Child is Subject To: Lung Disease (asthma or tuberculosis) Heart or Cardiac Condition Kidney Problems Migraines Sleep Walking Nervous or Mental Conditions DETAIL OF OTHER MEDICAL CONDITIONS: History of ALLERGIES (check those that apply, then provide detail below) Bee Stings Allergies to Medicine Food Allergies Other Allergies DETAIL OF ALLERGIES: Please List Your Child s Medication(s) That Will be Brought to Camp (If none, please indicate with N/A) : Name of Medication(s and dosage): Check Time(s) When Medication(s) Need(s) to be Administered: Page 3 of 5

4 HEALTH INFORMATION STATEMENT Check below any information you feel staff and/or volunteers may need, to maximize the safety and the well-being of the exhibitor or staff member. To the right of the condition statement is space for more information relating to the condition checked. Please be specific. In case of emergency, this health information may be the only source of accurate, important information. [ ] Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever) [ ] Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis) [ ] Arthritis, Diabetes, Kidney or Bladder Disease [ ] Impaired Sight or Hearing, Chronic Ear Infections [ ] Recent Surgical Operation, Accidents or Injuries [ ] Any Infectious Disease [ ] Skin Disease [ ] Under on-going care of a Physician (NAME & PHONE #) for chronic or recurring problem [ ] Do you wear glasses? YES[ ] NO [ ] SOMETIMES [ ] [ ] Do you wear contact lenses? YES [ ] NO [ ] SOMETIMES [ ] [ ] Date of last FLU SHOT [ ] Significant Orthopedic and/or Neuromuscular Impairment (e.g. loss of limb, spinal cord injury) Primary Care Physician: Clinic/Hospital Affiliation: City: State: Phone: _( ) - Health Insurance Provider: Owner's Name: ID/Policy Number: Medical Privacy Statement: It is the policy of University of Illinois Extension 4-H Youth Development Programs to keep any medical information it may have regarding 4-H Youth Development program participants confidential. However, there may be time in which such medical information will be needed and may need to be shared with others. Examples of sharing might include: providing information to medical personnel in the event of an emergency so that a youth may be treated; providing information to Extension staff or volunteers who are coordinating specific events in the case of a request for reasonable accommodation; and providing information to chaperones or host families who are responsible for the health and safety of program participants at a specific event. Except in the case of emergency, prior to sharing any medical information, it may have with those external to the University, Extension, or 4-H, every effort will be made to get the permission of the program participant or parent or guardian. As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given. I further understand that in case of serious illness/injury, I will be notified. However, if it is impossible to contact me, I give my permission for emergency treatment, x-ray or surgery, as recommended by an attending physician. I also understand that any accident insurance in effect (IF PROVIDED) for the event does not cover pre-existing conditions or self-inflicted injuries. Camper s First Name Camper s Last Name SIGNED: Parent or Guardian DATE: Issued in furtherance of Cooperative Extension Work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, D. R. Campion, Director, University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension provides equal opportunities in programs and employment. *The 4-H Name and Emblem are Protected Under 18 U.S.C Page 4 of 5

5 AGREEMENT TO ASSUME RISK AND RELEASE FROM LIABILITY 4-H Medium to High Activity NAME OF EVENT: 4-H Summer Youth Camp DATE(S) all June and July sessions YEAR 2018 The Activity is a residential summer youth camp. This is a legal document. You must read and understand it before signing it. I acknowledge that there are certain risks, hazards and dangers, including risk of physical injury, disability, or death and risk of loss of use or damage to my personal property as a result of allowing my child to participate in this Activity. 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 from the use of equipment, materials, or facilities recommended by the University of Illinois; environmental conditions; from the acts or omissions of others; or from the unavailability of immediate and/or adequate emergency medical care. I understand that the University of Illinois does not guarantee the personal health or safety for participants, nor does it protect against risk of loss of personal property. I verify that I have knowingly disclosed all pertinent medical and health information about my child in the UI Extension 4-H Program Youth Emergency Medical Information form, which I have completed and signed. (May be crossed out if not applicable.) If my child is injured or becomes ill, and/or causes harm to another person or another person s property while participating in this Activity, I will accept responsibility for any losses and medical bills, including co-payments and deductibles not covered by the American Income Life Medical/Accident insurance policy, if purchased in conjunction with this Activity. I will not seek reimbursement from the University of Illinois. I understand the University of Illinois does not assume responsibility for events that are not part of the Activity described above, or that are beyond the control of the University, its employees, its agents, or its volunteers, or for situations that may arise due to the failure of the participant to disclose pertinent information. My child and I understand and agree to abide by the Youth Behavior Guidelines provided by University of Illinois Extension 4-H. I understand that the UI Extension has the right to ask my child to leave the Activity if a UI representative deems that my child s behavior or action poses a threat to others participating in the Activity. I affirm I have reviewed and understand the pertinent safety policies. (May be crossed-out if not applicable.) In consideration for allowing my child to participate in the Activity, I release the Board of Trustees of the University of Illinois, its officers, employees, agents and volunteers from any and all liability, and waive any and all claims that my child and I may have, arising out of or in any way connected with the Activity and my child s participation in the Activity. This release and waiver is binding on my heirs, assigns and representatives. Camper s First Name Camper s Last Name Parent/Guardian First Name Parent/Guardian Last Name Parent/Guardian Street Address _ City State Zipcode Parent or Legal Guardian's Signature Assumption of Risk & Release 4H medium to high physical activity/approved for legal form RM page 5 of 5