2013 National 4-H Shooting Sports Teen Leadership Institute

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1 2013 National 4-H Shooting Sports Teen Leadership Institute July 25-28, 2013 Louisiana State University, Baton Rouge, Louisiana Application Packet Deadline June 21, 2013 to your 4-H Shooting Sports State Coordinator Two applications from each state will be accepted. Prepare a complete application packet and mail or to your state 4-H Shooting Sports Coordinator. They will select two applications to forward onto Lisa Muzzey, National 4-H Shooting Sports Committee. 4-H Shooting Sports member must be at least 14 years of age to apply. The cost of transportation to the event will be the responsibility of the participant. All lodging (including linens), meals, transportation during the event and materials will be provided. Participants should plan to arrive between 6:00-9:00pm on 7/25 and the event will end 12:00pm on 7/28. Transportation to and from the Baton Rouge Metropolitan Airport will be provided. A completed packet includes the following: 1. Application Form 2. Certification Form (with all signatures, to include your State 4-H Shooting Sports Coordinator) 3. Letter of reference from your state 4-H Shooting sports Coordinator 4. Resume for Teen Applicant - Include School, 4-H, Community memberships, activities and awards 5. University of Louisiana 4-H Behavioral Expectation Form 6. University of Louisiana Parent Permission Page (includes medical treatment permission, photo video/photo permission and participation in activities permission) 7. University of Louisiana Overnight Permission Form 8. One 5x7 - Portrait Color Photograph & Digital Copy (jpg or tiff) Lisa Muzzey, 4-H Shooting Sports Coordinator UVM Extension 307 South Street Springfield, VT Phone: lisa.muzzey@uvm.edu

2 2013 National 4-H Shooting Sports Teen Leadership Institute Application Form Name: Preferred First Name: Address: City: State: Zip: Home Phone Number: Cell Phone Number: Address: County: Club: of Birth: Age (as of Jan. 1 of current Year): Years in 4-H: Grade in School: Grade Point Average (GPA): List Local Newspaper/Media Outlet: Years in 4-H Shooting Sports (check those that apply): Archery Hunting Muzzleloading Pistol Rifle Shotgun The following information is to assure that any clothing ordered for you will fit properly. Polo Shirt Size: T-Shirt Size:

3 Certification Form I will be active in my club and county 4-H program, as well as maintain an acceptable academic standard in school during my service as a 4-H Shooting Sports Ambassador. Further, I am willing to conduct myself in the highest standards expected of an Ambassador. Applicant s Signature We (I) understand that our (my) son/daughter wishes to serve as a 4-H Shooting Sports Ambassador. We (I) will support him/her in fulfilling the responsibilities should he/she be selected. Parent/Guardian Signature Parent/Guardian Signature We certify that the above named 4-H er is enrolled, active and in good standing in our 4-H shooting sports club and county 4-H program. We support his/her application for the position of 4-H Shooting Sports Ambassador. 4-H Club Leader Signature Extension Agent Signature State 4-H Shooting Sports Coordinator Signature :

4 National 4-H Shooting Sports Ambassador Program Guidelines National 4-H Shooting Sports Ambassador Program is designed to promote 4-H and specifically 4-H Shooting Sports. Youth selected to serve as Ambassadors will receive training that will allow them to return to their homes and advocate for the program at the county, regional, and state level. Some Ambassadors may be asked to support national events as well. Ambassadors provide public relations support at special events such as donor/sponsor functions and also serve as spokespersons for the 4-H Shooting Sports Program, helping to make 4-H and the 4-H Shooting Sports Programs more visible. The Ambassador s further develop their skills in leadership, public presentation, citizenship, community service, public relations and team building. PURPOSE, GOALS, OBJECTIVES The 4-H Shooting Sports Ambassador program will provide a venue for 4-H Teens to: 1. Represent 4-H and specifically 4-H Shooting Sports for public relations purposes at special events; at donor/sponsor functions and with the general public, 4-H groups, community service organizations, schools and media contacts. 2. Serve as spokespersons for the 4-H Shooting Sports program at their respective levels of participation national, regional, state, county - helping to make 4-H Shooting Sports programs more visible. 3. Further develop their skills in leadership, public presentation, citizenship, community service, public relations and team building. 4. Assist in maintaining relations with 4-H Faculty and Extension Administrators as well as past, present and future program donors and supporters. 5. Continue and expand their involvement in 4-H Shooting Sports beyond the shooting skills and competitive levels. 6. Stay actively connected with the 4-H Shooting Sports program as they enter their collegiate years and further into adulthood. PROGRAM EXPECTATIONS By being selected as a National 4-H Shooting Sports Ambassador, you will be representing over 320,000 4-H youth. What you say and do is very important. Remember, you never get a second chance to make a good first impression. As an Ambassador you may meet with donors who are CEO s of companies or organizations and you always need to put your best foot forward. The way you dress, the way you talk and act are very important when you are serving as an Ambassador.

5 You are expected to be on time, so plan to be early to any event. You need to respond promptly to any s or phone calls from the Program Coordinator and your chaperon for the event. It is very important that you send thank you notes immediately following the event. You will be given names and addresses so that you can fulfill this obligation. You may get tired at events, but you always need to be cheerful and ready to respond positively to everyone. A mature attitude and outlook is required. Ambassadors may be asked by your State Shooting Sports Coordinator or the National Shooting Sports Committee to serve as a representative at a local, regional, state, or national event. BEHAVIORAL EXPECTATIONS A goal of the 4-H Shooting Sports Ambassadors program is to provide opportunities for youth to build character and develop their leadership skills. Ambassadors are expected to uphold the 4-H Code of Conduct at all times. DRESS CODE Ambassadors are expected to dress in a manner befitting young men and women. Modesty, neatness, well groomed and practicality will be the guiding principles. Attention to details is important, so here are some tips for both men and women. Make sure you have: clean and polished conservative dress shoes well-groomed hairstyle cleaned and trimmed fingernails minimal cologne or perfume no visible body piercing beyond conservative ear piercings for women well-brushed teeth and fresh breath no gum, candy, or other objects in your mouth minimal jewelry no body odor Ambassadors are not to wear torn (intentional or otherwise) or sloppy clothing. Tank tops, muscle shirts, bare midriffs, low necklines, sundresses, and tight or otherwise revealing clothing will not be allowed. This applies to all spandex fashions. T-shirts with negative, outlandish, disrespectful messages or pictures will not be allowed. Ambassadors are to have no visible tattoos. Ambassadors may wear shorts and skirts of modest style and length. Shorts, skorts and skirts may be no shorter than 3 above the knee. Females - Blouses/shirts must be tucked in when low-rise slacks/jeans/skirts/ are worn. Males Casual or dress slacks should be worn with shirttails tucked in. All footwear should be clean, neat, shined and no flip flops. When serving as a National 4-H Shooting Sports Ambassador, you need to remember that you are representing the 4-H Shooting Sports youth to the public and you need to make the best impression possible.

Each club member will be expected to participate fully in all programs and uphold exemplary standards of behavior.

6 Code of Conduct for 4-H Events Rules and regulations governing 4-H events will be discussed by agents and leaders with 4-H ers before the event. 4-H ers are under the supervision of all Extension personnel and other adults helping with the event. Each club member will be expected to participate fully in all programs and uphold exemplary standards of behavior. The following are grounds for sending 4-H ers home at their parents expense and may be grounds for suspension in district, regional and state events for up to 12 months. o Possession or use of illegal drugs, alcoholic beverages, tobacco products, pocket-hunting knives, fireworks or firearms. o Misuse or abuse of public or personal property. (Individuals responsible will also be required to pay for damages). o Disrespect for the authority of agents, leaders and specialists (such as failing to follow specific rules or instructions for the event or using abusive language). o Unauthorized absence from the premises of the event. o Unauthorized use of vehicles during the event. o Unauthorized possession of firearms and other weapons. o Breaking curfew or disturbing the peace (for example, being late for dormitory checks or disturbing others after lights out). o Unauthorized presence in room of a member of the opposite gender without permission of agent or leader. Realizing these guidelines are not all inclusive, the LSU AgCenter reserves the right to adjust these policies. Decisions on discipline will be the responsibility of the Extension agent(s) supervising the event in consultation with others designated as supervisors. Signature of 4-H er Signature of Parent/Guardian

7 Louisiana 4-H Overnight Event Permission/Health Form (To be completed and signed prior to event. Participant MAY NOT register without a health form.) [ATTACH PHOTO HERE] **Please note that you will need a social security number for admittance to Rapides General Hospital in Alexandria.** Event or Activity Name of Participant of Birth First Middle Last Address Street or PO Box City State Zip Code Parish Parent/Guardian (for youth) Name: Phone: Home Work Cell Family Physician Phone: Office Alternate Health Insurance Company Name & Address: Group No. Policy No. Name of Insured: Emergency Contacts: 1) Name: Phone: Home Work Cell 2) Name: Phone: Home Work Cell Health History: List all known drug allergies/allergies: Is there past or present history of the following? Check all that apply. Yes No Yes No Appendicitis Joint/back or limb pain Allergies/sinus problems Arthritis or other conditions Asthma/persistent cough Kidney or liver disease Bedwetting Menstrual problems Bleeding disorder Nervous condition/depression Convulsions/fainting Nose problems Diabetes/hypoglycemia Physical Disability Epilepsy/convulsion/fainting Poison ivy/oak/sumac rash Eye/ear problems Recent surgery/injury Frequent ear infections Serious illness Gall bladder problems Serious injury Heart defect/disease Skin/gland problems Hernia Sleepwalking Hypertension Stomach/bowel problems Hyperactivity/ADD/ADHD Tuberculosis Infectious disease Ulcers (stomach/intestines) Insect stings* Urinary problems *Localized redness/swelling do not constitute insect allergy. Body-wide rash, swelling, and difficulty breathing do constitute insect allergy (anaphylaxis). Health Form Revised 04/12/2011

8 Explain any Yes items and list any other problems, including the diagnosis, date of injury or illness, hospital, length of hospitalization, name of doctor, etc. List any exposure to infectious disease in the two weeks prior to event. (Attach a page if extra space is needed for explanation) Immunizations (latest date): Tetanus Hepatitis Special or Prescription Medications: Please list any special medication being taken including the name and phone number of the prescribing physician, dosage, consumption rate and interval. Name of Medication Dosage Frequency Prescribing Physician & Number Special Restrictions: Chronic or recurring illness and treatment which may be needed Dietary modifications require physician s written instructions be given to 4-H staff two (2) weeks prior to the event. Statement of Health: To my knowledge, I have no health problems, unless stated earlier, and can SAFELY PARTICIPATE in this event. I would rate my health as: (please circle one) POOR FAIR GOOD EXCELLENT. I have no contagious or communicable disease and have had no illness within 30 days that would preclude me from participating in this event. If I do have any health problems or illnesses, they are explained in the space provided on page one. Insurance Information: LSU AgCenter insures all participants while they attend 4-H sponsored events. This insurance is limited to $3,000 and does not cover crutches. Remaining medical bills are the responsibility of the participant and his/her parent or guardian. It is the policy of the Louisiana Cooperative Extension Service that no person shall be subjected to discrimination on the grounds of race, color, national origin, gender, religion, age, or disability. Health Form Revised 04/12/2011

9 Parent Permissions Page PERMISSION FOR: Child s Name Parent/Guardian Authorization for Medical Care: I, the undersigned parent/guardian, understand that although the 4-H staff closely supervises the participants, the 4-H staff is not responsible in cases of accidental injury or illness. In the event first aid is necessary; it will be available on site. I give permission to the physician selected by the 4-H staff to order x-rays, routine tests and treatment for the health of my child, and in the event I cannot be reached in an emergency, I give permission to secure proper treatment for (hospitalize, order injections and/or anesthesia and/or surgery) my child. I (parent) hereby give permission for Louisiana 4-H to administer the following over-the-counter medications if the nurse/med tech deems it necessary. Dosages will be administered according to directions on the bottle unless a parent or physician directs otherwise. Circle any item(s) you do NOT want administered to your child. Aleve Antibiotic ointment Anti-diarrheal medicine Antihistamine liquid or pill Aspirin Bismuth subsalicylate (stomach relief liquid) Benzocaine swabs Caladryl Lotion Calamine Lotion Eardrops Eye Wash Hydrocortisone cream Ibuprofen Laxative Lip Balm Midol Milk of magnesia Muscle Rub Pamprin Sinus/Cold Medications Sunburn Lotion Swimmer s Ear Drops Throat spray or lozenges Tylenol Parent/Guardian Authorization to participate or exclude participation in event activities: I give permission for my child to participate in all event activities with the following exceptions: Membership and participation in activities and events are open to all citizens without regard to race, color, nationality, origin, gender, religion, age, veteran status, or disability. If you have a disability that requires special accommodation for your participation in this event, please contact your parish 4-H agent two (2) weeks prior to your participation in this event. Indicate if your child has special requirements for travel/lodging or dietary needs due to disability or medical restrictions. For an optimum experience for your child and to safe guard all campers, please evaluate if your child should attend camp if they are exhibiting these symptoms: (List of symptoms including fever, lice, ring worms, etc.). For the health and welfare of all campers, if you re child exhibits these symptoms while at camp, you will be contacted to pick your child up from camp. Persons designated to take child from event: Persons not permitted to take child from event: Note: Your child may be photographed or videotaped for promotional or educational purposes. I understand my child may participate in and/or complete surveys and evaluations that will be used to determine 4-H program effectiveness or to promote the program. Youth will be asked their consent before completing a survey or evaluation. Participation in surveys and evaluations is voluntary and does not affect eligibility to participate in the 4-H program. I DO NOT agree to these terms. By my signature I am verifying that all the above information on the Louisiana 4-H Overnight Event Permission/Health Form is true and accurate. Parent/Guardian Parent Permissions Form Revised 03/29/11

Teen Leadership Camp July 25, 2012 July 27, LSU Campus Baton Rouge, LA

Teen Leadership Camp July 25, 2012 July 27, 2012 LSU Campus Baton Rouge, LA Come join in the fun at the Louisiana Operation: Military Kids Teen Leadership Camp. You are invited to attend a two night camp