4-H Countywide Youth Lock-In Friend Registration Form

Transcription

1 4-H Countywide Youth Lock-In Friend Registration Form Who?- Youth in Grades 4 th -8 th Where?- Kettle Moraine YMCA 1111 West Washington Street, West Bend When?- 8:00pm Saturday December 2 nd until 6:00am on Sunday December 3 rd. Registration: 7:45-8:00pm (Please be prompt!) Cost: $15.00 per person Why?: Enjoy a great evening filled with: Open Gym, Cool Craft Activities, Structured Games, Swimming, Quiet Room with Movies, Virtual Vault, Racquetball, Dodge Ball, Plus a lot more! What to Bring: Swim suits, towels, sleeping bag and pillows! (Please label EVERYTHING and make sure it is 4-H appropriate!) What not to Bring: Food, Makeup, Gum, Money, Soda, ALL Electronic Devices! Important Notes: *Doors will lock at all times! *If you would like to pick up your child early you may do so at 12:00am. *Subs will be served at 10:30pm. *Parent/Guardians must inform chaperones of any medication at check-in. *At least one adult (21 or older and a registered leader in 4-H!) is required to chaperone youth from EACH PARTICIPATING club. Chaperone is REQUIRED to sign your form, so they know who is coming from the club. *If your child plans to swim please have them come with their swim suits under their clothes. Any questions please call: 4-H office at If you have questions on the day of the event, please call Teresa at or Melissa at Lock In- December 2-3, 2017 Youth Registration Friend Registration Form Name Grade Phone Address Chaperone s Name Parent s Name Signature Signature I am coming with (4-H member s name) to the 4-H Lock-In. Sub Choice: Ham Turkey When are you leaving? Leaving Early (12:00am) Staying the whole time! Make sure to turn in all of the following together: 1. Registration form (one per youth) 2. Health Form (one per youth) 3. Signed Youth Behavior Form (one per youth- picked up at the 4-H office or found here: h-youth-development/events/) 4. $15.00 per youth participating! (Please send a check only! NO CASH!) *Make check payable to: Washington County 4-H Leaders Association Send all of the above items to: 4-H Lock-In; 333 E. Washington St., Suite 1200, West Bend, WI Due: Wednesday, November 15 th, 2017 An EEO/AA employer, University of Wisconsin-Extension provides equal opportunities in employment and programming, including Title VI, Title IX, and the Americans with Disabilities Act (ADA) requirements.

2 University of Wisconsin Extension 2017 Youth Event Health Form Event Name: 4-H Lock In s: December 2-3, 2017 Youth Name: Birth date / / Age on 1 st day of event Sex: Male Female Custodial Parent/Guardian (or spouse) address: Phone s: Home ( ) - Work ( ) - Cell phone ( ) - Home address: Street City State Zip Second parent/guardian and/or emergency contact: Phone: Home ( ) - Work ( ) - Address: Street City State Zip Yes No Health Conditions (check) Asthma Diabetes Epilepsy Psychiatric Cognitive/Developmental Any dizziness, light-headedness or fainting associated with exercise within the past year? Any unexplained, rapid or irregular heart beat within the past year? A physician has sometime denied or restricted participation in sports due to a heart problem. Yes No Allergies (check) List specifics Insect stings Foods Medications Other Do any allergies require an EPIPEN injection? Is insulin required and carried by youth? Is an inhaler required and carried by youth? of last Tetanus booster: (mm/dd/yy) Name of Insurance Co.: Policy #: Medications camper will be taking during event/camp: Medication #1 Reason Dosage (mg) Times of day given Prescribing Physician & Phone 1

3 UW - Extension Youth Event Health Form (Continued) Participant Name: Parent/Guardian Signature: Medication #2 Reason Dosage (mg) Times of day given Prescribing Physician & Phone Medication #3 Reason Dosage (mg) Times of day given Prescribing Physician & Phone Medication #4 Reason Dosage (mg) Times of day given Prescribing Physician & Phone Programs may have limited over-the-counter medications available. Select medications that can be administered, if available. Acetaminophen (Tylenol): Yes No Hydrocortisone (anti-itch) cream: Yes No Benadryl: Yes No Ibuprofen: Yes No 2

4 CONSENT FOR MEDICATION ADMINISTRATION AND MEDICAL TREATMENT TO THE PARENT(S) OR LEGAL GUARDIAN: If your son, daughter, or ward will be under the age of 18 while participating in a University of Wisconsin Extension event/camp/program, it is event/camp/program policy to secure your consent for medication distribution and for the use of medical devices. The medication or medical device must be administered by designated event/camp/program health staff with the exception that a limited amount of medication for life-threatening conditions may be carried and administered by my son/daughter/ward (i.e. bee sting kit, inhaler, insulin syringe). It is event/camp policy to secure your consent for medication distribution and for the use of medical devices by signing below. Please check all that apply: Yes No No medication(s) has been brought to event/camp. Prescription medication(s) has been brought to event/camp. All prescription medication must be in the original medicine bottle and labeled with the youth participant s name, doctor s name, medication name, dosage, prescription number, date prescribed, and instructions. Also, information about any prescription medications must be provided in writing to event/camp health staff with the information requested in the later section of this form. Over-the-counter medications have been brought to event/camp and may be administered by event/camp health staff as needed. All over-the-counter medications must be labeled with the youth participant s name, medication name, dosage and instruction. If your son, daughter, or ward will be under the age of 18 years while at the event/camp, it is our policy to secure your consent for all of the following. By signing below, I am giving my consent in advance for medical treatment at an appropriate medical facility in case of illness or injury. I am stating that I am aware of and accept the risk inherent in the program activity. I attest that all information on this form is correct and up-to-date, and that I will provide any and all significant material, and important changes to any information in this form to event/camp staff no later than check-in. I agree to hold harmless and indemnify the Board of Regents of the University of Wisconsin System, and the University of Wisconsin Extension, their officers, agents, and employees from any and all liability, loss, damages, costs, or expenses which are sustained, incurred or required arising out of the actions of my son, daughter or ward in the course of the event/camp. Participant Name (Please Print) SIGNATURE OF PARENT OR LEGAL GUARDIAN This is the approved health form for 4-H events and camps. 3

5 4-H Lock-In Expectation Statement Dear Parent and Youth: Washington County 4-H strives to provide a positive learning experience for youth. Their health, welfare, and positive development is our most important consideration. We want to be sure that Friends of 4-H members who attend the Lock In understand the expectations that will help keep this event safe and fun. Please read and discuss the following expectations: Youth should be responsible and conduct themselves in appropriate manner. Youth are expected to respect the rights of others and to listen to youth leaders and adult chaperones during the event. Youth are expected to participate in activities. Youth are expected to abide by the guidelines of the Kettle Moraine YMCA facility. Youth are expected to respect personal and public property. Parent(s) or guardian may be held financially liable for any damage beyond reasonable wear and tear. Youth will not leave the premises of the Kettle Moraine YMCA during the Lock In without expressed permission of chaperone or adult advisor. Youth are expected to refrain from using obscene or objectionable language; including racial or ethnic slurs. Youth will not bring or use tobacco, alcohol, or unauthorized drugs during this 4-H activity. We ask that participants and their families understand a chaperone s role during the Lock In: To serve as an advocate for the youth. To maintain regular contact with participants to monitor health, attitude, behavior, problem situations, etc. To make appropriate decisions in emergency situations to enhance the health and well-being of the members. To have responsibility to determine the occurrence of inappropriate behavior and take appropriate action(s) which may include: o Counseling with involved member(s) to reach an understanding and cessation of the inappropriate behavior. o Taking disciplinary actions at the time of the occurrence (not to include physical punishment). o Informing parents and local Extension personnel of misbehavior at time of occurrence if severity warrants such notification. o Deciding to remove a member from the program and send the member home early at the expense of the member s family. I agree to meet these expectations and I understand the chaperone s role. Youth Signature Signature of Parent/Guardian Yes No Yes No I grant 4-H Youth Development, UW-Extension and the University of Wisconsin Board of Regents the right to publish, and copyright my image (including audio, moving image or photography) for educational programs, websites, and promotion of its programs. I require an accommodation for a disability to participate in this program.