4-H Music Education Matters Summit Scholarship Application Open to all youth 8 th -12 th grade Scholarship Deadline: May 1, 2018 by 4:00pm

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2 4-H Music Education Matters Summit Scholarship Application Open to all youth 8 th -12 th grade Scholarship Deadline: May 1, 2018 by 4:00pm Please type or print using black ink. Scholarship covers travel from the Alabama 4-H Center to Rock Eagle Georgia 4-H Center, meals, and lodging for 2 days and 3 nights. Trip Dates: July 17th-19th Submit Completed Application Via by May 1, :00pm: Rebecca Danley, 4-H Foundation Regional Extension Agent Student s Full Name (First, Middle, Last) Age Grade County School T-Shirt Size Telephone Number(s) Area of Interested (Circle ONE-this is where you will be during camp) Vocal Instrumental Dance Musical Theater Songwriting Please tell the Scholarship Committee why you want to attend the 4-H Music Education Matters Summit: What are your future plans for working in the music/theater/arts industry? List your 4-H Involvement/Community Service: ***Submission Requirement: MUST be a current HOnline enrolled and active 4-H Member. A completed scholarship application, 1 letter of reference from someone other than a relative, GA Code of Conduct Form, GA Medical Form, GA Medicine Form, and Alabama 4-H Youth Consent Form MUST be submitted with this application in order to be considered for this scholarship.*** I authorize the release of the information provided on this Scholarship Application to the Scholarship Committee and Alabama 4-H. Applicant Signature Date Parent/Guardian Signature Date

3 GEORGIA 4-H CODE OF CONDUCT 4-H ers Name: County Address: Phone School: Grade: Year: BEHAVIOR STANDARDS The Georgia 4-H Code of Conduct is valid for one year and applies to all activities coordinated through Georgia 4-H. 4-H ers are expected to attend all sessions as part of a planned program exhibiting positive character and behavior including (but not limited to) trustworthiness, responsibility, respectfulness, caring, citizenship and fairness. 4-H ers are expected to be responsive to the reasonable requests of leaders and respectful of the needs for their personal safety and the safety of others. 4-H ers should dress appropriately, use appropriate language and respect the rights of others. 4-H ers may not behave recklessly or in a manner which prohibits others from participating in the program in the manner intended. 4-H ers may have access to technology at UGA/CES offices and facilities. Technology use is for educational purposes. 4-H ers may not access inappropriate websites or materials. Realizing these guidelines are not all inclusive the University of Georgia Extension staff and volunteers reserve the right to make adjustments to these policies. CONSEQUENCES OF MISBEHAVIOR 4-H ers and adults who observe a breach in the Code of Conduct must report the misbehavior to the appropriate leader. The leader will complete an incident report and determine the next steps regarding the incident. If 4-H ers are found participating in actions listed below, law enforcement or other legal authorities may be notified and may lead the review and consequences related to the incident. In these incidents, 4-H ers may be removed from the event and suspended or expelled from future 4-H participation. These behaviors may include, but are not restricted to: Possession or use of illegal drugs Possession or use of a weapon Assault or harassment Inappropriate sexual behavior If the 4-H er is found participating in the actions listed below, 4-H leaders may be notified and may lead the review and consequences related to the behavior. 4-H ers misbehaving will have the opportunity to explain their actions to leaders in charge of the activity and may request a review board. The person coordinating the event may also convene a review board for the purposes of determining what has occurred and what disciplinary action should be taken. A review board will consist of one Extension faculty or staff member, two volunteers and three 4-H members. The Extension faculty member coordinating the event will serve as chairperson. In some cases, incidents are deemed serious and may be referred to law enforcement or other legal authorities. If the 4-H er receives consequences from the leader or through the review process, his/her parents/guardians may be notified; the 4-H er may be sent home at the parents expense and may be suspended from participation in 4-H events. Suspensions may be up to one year. If a 4-H er wishes to appeal the decision of the review board, the 4-H er must appeal in writing through the County Extension office. Appeals must be filed within 10 days of notification of the disciplinary action. The appeal is sent to the Program Development Coordinator of the 4-H member and the State 4-H Leader for ruling by the State 4-H Leader. Following any disciplinary review, the person coordinating the activity will provide written notification to the appropriate parties including but not limited to the 4-H er, his/her parent/guardian and his/her county Extension faculty member. Breaking curfew or disturbing the peace Unexcused absences from the activities or premise of an event Unauthorized use of vehicles during the event Reckless or inappropriate behavior Use of foul or offensive language Possession or use of alcohol or tobacco Breach of the 4-H Code of Ethics Remaining in the presence of those who are breaking the 4-H Code of Conduct Theft, misuse or abuse of public or personal property Possession of fireworks PARENT/GUARDIAN & 4-H er AGREEMENTS Release Waiver of Liability and Covenant Not to Sue I have read the Georgia 4-H Code of Conduct and agree to participate fully in all aspects of program activities. I understand the standard of behavior and agree to maintain such during 4-H programming. 4-H ers Signature Date I have reviewed the Code of Conduct and agree to all of its provisions. For the sole consideration of the Cooperative Extension Service s arranging for participation in 4-H programming, I hereby release and forever discharge The University of Georgia, the Board of Regents of the University System of Georgia, their members individually, and their officers, agents and employees from any and all claims, demands, rights and causes of action of whatever kind that I may have, either on my own behalf or in my capacity as a legal representative of my child, arising from or in any way connected with my child s participation in 4-H. I further covenant and agree that for the consideration stated above I will not sue the Institution, the Board of Regents of the University System of Georgia, its members individually, its officers, agents or employees for any claim for damages arising or growing out my child s participating in the program. I understand that the acceptance of this Release, Waiver of Liability, and Covenant not to sue the Board of Regents of the University System of Georgia shall not constitute a waiver, in whole or part, of sovereign immunity by said Board, its members, officers, agents, and employees. I certify that my child is participating in 4-H with my knowledge and consent. I have read and understand all of the above policies. I hereby grant permission my child s images, likeness, and voice to be recorded in any media during this program and to be used by the University of Georgia and Georgia 4-H on behalf of the Board of Regents of the University System of Georgia in any publications, media, or technology now known of or hereby developed in the future for any lawful purpose whatsoever without further permission from me. I understand I will not be compensated further for use of these recordings. Parent/Guardian Signature Date Phone VALID FOR ONE YEAR FROM DATE OF SIGNING Revised 6/2016

4 Georgia 4 H Medical Information & Release Form This form should be completed prior to each 4 H event. EVENT: Date(s) of EVENT: Name Address 4 H ers Information County Date of Birth Grade Gender Preferred Phone Parent/Guardian Information Name: Preferred Phone: Alt. Phone: Address: Text: Name: Preferred Phone: Alt. Phone: Please list the names of two adults other than parent/guardian who may be contacted in case of emergency. Name: Preferred Phone: Alt. Phone: Name: Preferred Phone: Alt. Phone: Medical Information The following information is requested in case of accident or illness to better treat your child. The information is optional and not required for participation. Name of Physician: Phone: Date of Last Physical Examination: Drug Allergies: Other Allergies: Describe any recent illness or injury: Describe any pre existing conditions: Describe any other circumstances that would help leaders or medical professionals in working with the 4 H er: PARENT/GUARDIAN AGREEMENT: I understand that should a health problem arise, I will be notified but that if I can not be reached by telephone, such medical treatment, including surgery, as deemed necessary by competent medical personnel could be rendered; that such necessary information may be released for insurance purposes and that I understand the limitation of the coverage as indicated below. Furthermore, I am aware that participation in 4 H programming includes risk including, but not limited to, transportation to/from events, sports and recreational games, ropes courses, water activities, hiking, as well as risks that are not foreseeable. For the sole consideration of the Cooperative Extension Service s arranging for participation in 4 H programming, I hereby release and forever discharge The University of Georgia, the Board of Regents of the University System of Georgia, their members individually, and their officers, agents and employees from any and all claims, demands, rights and causes of action of whatever kind that I may have, either on my own behalf or in my capacity as a legal representative of my child, arising from or in any way connected with my child s participation in 4 H. I further covenant and agree that for the consideration stated above I will not sue the Institution, the Board of Regents of the University System of Georgia, it s members individually, its officers, agents or employees for any claim for damages arising or growing out of my child s participating in the program. I understand that the acceptance of this Release, Waiver of Liability, and Convent not to sue the Board of Regents of the University System of Georgia shall not constitute a waiver, in whole or part, of sovereign immunity by said Board, its members, officers, agents, and employees. I certify that my child is participating in 4 H with my knowledge and consent. I have read and understand all of the above policies. I hereby grant permission for my child s images, likeness, and voice to be recorded in any media during this program and to be used by the University of Georgia and Georgia 4 H on behalf of the Board of Regents of the University System of Georgia in any publications, media, or technology now known of or hereby developed in the future for any lawful purpose whatsoever without further permission from me. I understand I will not be compensated further for use of these recordings. Parent/Guardian Signature Date 9/23/2016 PLEASE COMPLETE BOTH SIDES

5 Over the Counter & Prescription Medication Summary 4 H ers Name County Parent/guardian should list any over the counter medication that may be given to the 4 H er in case of illness. In addition, list any/all medication routinely taken by the 4 H er including prescription and over the counter medications. Check Yes or No to indicate if you allow your child to receive the following medications while participating in 4 H programming. 1. Administration of Acetaminophen (Tylenol ) or Ibuprofen (Motrin or Advil ) at an age appropriate or weight appropriate dose for discomfort, pain, or fever *** Parent/Guardian will be contacted if student s fever is 100 F or higher. 2. Antacid liquid or Antacid tablets for indigestion/minor stomach discomforts and at an age appropriate dose 3. Diphenhydramine (Benadryl) for symptoms of allergic reactions, insect stings, or rashes at an appropriate dose 4. Sore throat relief spray for sore throat 5. Cough Drops for coughing 6. Itch and rash relief cream/ointment for minor skin irritations 7. Lubricating eye drops for eye irritations 8. Oral pain relief gel for tooth/mouth discomfort 9. Triple antibiotic ointment for minor skin abrasions/wounds Please list any prescription or over the counter medications your child is currently taking. This information is necessary if your child is to be treated by a medical professional. Examples: Claritin, vitamins, etc. If the following medication should be administered during this event, complete the Georgia 4 H Medicine Form. Medication Condition being treated for I am the parent/guardian of and give permission for the medications listed to be administered as directed. By signing below, I am agreeing the information is currently correct. Parent/Guardian Signature Date 9/23/2016 PLEASE COMPLETE BOTH SIDES

6 Georgia 4 H Medicine Form 4 H ers Name County: Date(s): This form should accompany any medication to be given at an event. Activity where medication may be administered: Please list any medication(s) your child will be taking while at the above event. (Attach additional page if necessary). Name of Medication: Illness/condition medication is being taken for: Date(s) medication is to be given: Time: Describe what the medication looks like? Describe dosage and special instructions: My child will be taking the above noted prescription or over the counter medication that I am providing while they are involved in the above activity. Parent/Guardian Signature: Date: To be completed by administering leader Date Time Leader s 4 H ers Notes 9/23/2016 ATTACH ADDITIONAL PAGES AS NECESSARY

7 Georgia 4 H Medicine Form Additional Page Name of Medication: Illness/condition medication is being taken for: Date(s) medication is to be given: Time: Describe what the medication looks like? Describe dosage and special instructions: My child will be taking the above noted prescription or over the counter medication that I am providing while they are involved in the above activity. Parent/Guardian Signature: To be completed by administering leader Date Time Leader s 4 H ers Notes Name of Medication: Illness/condition medication is being taken for: Date(s) medication is to be given: Time: Describe what the medication looks like? Describe dosage and special instructions: My child will be taking the above noted prescription or over the counter medication that I am providing while they are involved in the above activity. Parent/Guardian Signature: To be completed by administering leader Date Time Leader s 4 H ers Notes 9/23/2016 ATTACH ADDITIONAL PAGES AS NECESSARY

8 Confidential [This Box to Be Completed by ACES Staff] County: Date of Receipt by County: / / Alabama 4-H Youth Consent Form All items on this form must be completely filled out by the participant and his or her parent or guardian. If an item is not applicable or there is none, indicate that by using N/A or None (for example: no Family Doctor). If this form is not completed in its entirety, the youth will not be able to participate in 4-H activities. Youth s Name Last First Birth Date / / Age Female Male Month / Day / Year Home Address Home Phone ( Parent/Guardian Work Phone ( City State Zip ) ) Family Cell Phone ( ) Primary Emergency Contact Phone(s) ( ) Alternate Emergency Contact Phone(s) ( ) Youth s Doctor Phone ( ) Health Insurance Co. Policy # Name of Insured Relationship to Participant ATTACH A PHOTOCOPY OF YOUR INSURANCE CARD Publicity Release I authorize Alabama 4-H or its assignees to record or photograph my image and/or voice and that of my child (if under 19) for use in research, educational and promotional programs and hereby convey all rights in perpetuity in such recording, photo, video or other media rights, including but not limited to Alabama 4-H or its assignee. I also recognize that these audio, video and image recordings are the property of Alabama 4-H. No, I do not authorize use of my or my child s individual image or voice. Confidential HEALTH HISTORY Does the youth have or has ever had -- any of the following? Check Yes or No to each item. Please explain any Yes answers (noting the number of the item) in the space below or on additional paper. Reporting a health condition will not prevent you from participating and will be kept confidential. 1. Asthma Bronchitis Convulsions Diabetes Ear Infection Fainting Heart Condition Headaches Hypoglycemia Serious Insect Stings Wear Glasses Wear Contact Lenses Other Conditions Penicillin Allergy Aspirin Allergy Tetanus Allergy Other Drug Allergies Food Allergies Serious Ivy, Oak or Sumac Poisoning. 20. Other Allergies... Date of Last Tetanus Shot / / Please explain Yes answers and provide information on present medications, recent medical issues (including injuries and surgeries), allergic reactions, special dietary regulations, any specific activities to be restricted and other comments. These over-the-counter medications or generic equivalents may be administered to my child without contacting me: Antihistamine (Benedryl) Antacid Ibuprofen (Advil) Acetaminophen (Tylenol) Pepto-Bismol Decongestant Baby Aspirin Hydrocortisone Polysporin (antibiotic cream) Please contact me for permission prior to administering any over-the-counter medications. This form is valid for one year from signing. Please update all medical or other information as needed. [5/16]

9 Alabama 4-H Youth Code of Conduct Confidential I will exhibit good character and behavior, such as trustworthiness, responsibility, respect, caring, citizenship and fairness. I will value the rights of all others. As a 4-H member, I am committed to the policies of the Alabama Cooperative Extension System, Auburn University and Alabama A&M University. I will act and speak respectfully. I will not use language that belittles others or is disrespectful of individual differences. I will dress appropriately. Apparel including accessories must not have pictures or wording involving nudity, sex, weapons, violence, drugs, alcohol or tobacco. Apparel, accessories and equipment featuring culturally or racially insensitive images violates 4-H s values of respect, fairness and caring and will not be permitted. I will attend all sessions of planned programs. I will be responsive to the reasonable requests of leaders and comply with the need for personal safety. I will not use alcohol, drugs, or tobacco nor remain in the presence of anyone using them. I will not behave recklessly, engage in sexual misconduct, assault, threaten, or harm another person or abuse public or private property. When I have access to computers at Extension facilities, I will use the computer for educational purposes and will not access inappropriate Web sites. I recognize that these guidelines are not all inclusive and that the Alabama Cooperative Extension System may make adjustments to these policies. MEMBER: I have read the Alabama 4-H Youth Code of Conduct and agree to live up to the expectations. I realize my failure to do so could result in a loss of privileges during the event and/or in the future and may result in my being sent home at the expense of my parent(s) or guardian(s). 4-H Member Signature Date SURVEY & EVALUATION RELEASE I hereby give permission for my child (under 19 years of age) and give consent for myself, as a parent or guardian, to complete surveys and evaluations that will be used to determine program effectiveness or to promote the program. I understand that participation in surveys and evaluations is voluntary and that I and my child may choose not to participate and may withdraw from surveys or evaluations without impact on my or my child s eligibility to participate in the 4-H program. I understand that I or my child may be asked for consent before completing a survey or an evaluation. No, I am not willing to participate or give permission for my child to participate in any program evaluation. Confidential VERIFICATION I, (parent/guardian) understand that participants will be supervised and that if a serious illness or injury develops, medical and/or hospital care will be given. I hereby give permission to the attending physician or other health care professional to hospitalize, secure proper treatment for, and order injections, anesthesia, or surgery for me or my child and affirm that the information set forth in the Health History is true and correct to the best of my knowledge and belief. I understand that as a parent/legal guardian, I will be responsible for the cost of service or treatment. 4-H Member Signature Date Parent/Guardian Signature Date I have read and understand the Alabama 4-H Youth Code of Conduct, Publicity Release and Survey & Evaluation Release. 4-H Member Signature Date Parent/Guardian Signature Date I hereby agree that I understand the risks or have been given the opportunity to ask for information concerning risks involved in this activity and assume all risks and release Alabama 4-H, the Alabama Cooperative Extension System, local Extension offices, Auburn University, Alabama A & M University, the State of Alabama, the Alabama 4-H Foundation and 4-H Youth Development Center, and their trustees, agents, officers and employees, from all claims, demands, and causes of action of any kind, including claims of negligence, which may arise from participation of me or my minor child in any Alabama 4-H sponsored activity, and this release is specifically granted in consideration of the services, programs and activities. 4-H Member Signature Date Parent/Guardian Signature Date Issued in furtherance of Cooperative Extension work, acts of May 8 and June 30, 1914, and other related acts, in cooperation with the U. S. Department of Agriculture. The Alabama Cooperative Extension System (Alabama A & M University and Auburn University) offers educational programs, materials, and equal opportunity employment to all people without regard to race, color, national origin, religion, sex, age, veteran status, or disability. This form is valid for one year from signing. Please update all medical or other information as needed. [5/16]

10 COPY OF INSURANCE CARD Marion County Extension Office th Avenue SW Hamilton AL Office: (205) Mobile: (205) Fax: (205) The Alabama Cooperative Extension System (Alabama A&M University and Auburn University), is an equal opportunity educator and employer. Everyone is welcome!

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