REGISTRATION INFORMATION 2018 CENTRAL AREA 4-H HORSE CAMP DATES: June 7-10, 2018 Thursday 11:00 a.m. thru Sunday 4:00 p.m. LOCATION: Camp Shamineau (between Lincoln and Motley, 2 miles east of Hwy 10) ELIGIBILITY: For enrolled 4-H'ers in grades 3 and up. 4-H Cloverbuds are not eligible to participate. (Mature 3 rd graders may participate only if a parent or adult in charge of that 4-H er is present.) Since youth are responsible for the complete care and saddling of their own horse, we encourage parents of young 4-H ers to attend. All 4-H'ers must stay in the lodge/cabin. Parents are encouraged to come and may bring one horse. (Adults cannot ride in 4-H er classes.) Adults have the option of staying in a lodge/cabin or camping. Adults staying in the lodge or cabin will pay $185, which covers lodging, meals, Thursday night pizza and fees. All adults NOT staying in the lodge or cabin must stay in the campground. There will be no camping in the barn area. There is an additional $30 fee for those in the campground to cover costs. This means that they will pay the camping fee of $7.50 per night per person, plus $30 per person for the weekend. Anyone camping has the option of purchasing meals in the dining center plus the Thursday night Pizza. 4-H staff reserve the right to not invite a camper to attend if there has been misbehavior on his/her part in past years, including, but not limited to, unexcused absences at required sessions. COSTS: Full amounts must accompany registration. $185.00 4-H'ers in lodge/cabin, all meals for all days $185.00 Adults in lodge/cabin, all meals for all days $7.50/night Adults in campground, camping fee, no meals, per person per night $30.00 Adults in campground, expense fee, per person per weekend (in addition to camping fee) $35.00 Adults one night in lodge, no meals $5.00 Zip Line or alternate activity per person (4-H ers and adults)
$2.00 Insurance per adult MEALS AT DINING HALL FOR ADULTS NOT IN LODGE/CABIN: $7.00 Breakfast $7.00 Noon Dinner $7.00 Supper $7.00 Pizza Buffet (included in lodge/cabin cost); adults who are camping may purchase WORKSHOPS(TENTATIVE): Western Horsemanship/Western Pleasure, Games, English, Drill Teams, Trail Class, Craft, Showmanship, Western Heritage, Conditioning, Massage Therapy. OTHER: Coggins test 2018 test required bring proof of negative results make sure the results are legible!! 2018 vaccinations required. Includes sleeping sickness, tetanus, and influenza. Bring receipt if you give shots yourself or a veterinarian's letter. Insurance Youth are covered under their county policy. Insurance information must accompany registration and be signed by the county 4-H Program Coordinator (page 2 of Family Registration form). Adults must include the $2 insurance fee with their registration. Bring your own horse limit 1 per 4-H'er or adult. Horse must be 3 years or over and healthy. Camp staff has the option to not allow a 4-H'er or adult to ride the horse if it isn't healthy, sound, or safe. ADULTS MAY RIDE THEIR HORSE ONLY AT DESIGNATED TIMES AND IN DESIGNATED LOCATIONS. Bring your own feed, tack, equipment, and straw or shavings (needed for tie stalls). Helmets required (adults & 4-H ers) must be ASTM/SEI approved NO BIKING HELMETS! Some helmets will be available on loan from camp with a deposit. Group Placement You will ride as soon as you arrive to be placed in a group based on your skill level AND your horse s level of training. These groups will be assigned by 5:30 p.m. Thursday. If you cannot arrive by 4:00 p.m. on Thursday, you must notify staff. Stalling Stalls will be assigned by staff. These assignments are NOT based on when your entry comes in. Horses will be in tie stalls, paddocks (usually 2 horses in each), tied to trailers, or you may bring portable panels you can bring and set up by your trailer. If your horse won't tie, we suggest you either train it to do so or bring a different horse. The four arenas in the barn area will be used at night for those who tie to trailers on a rotating basis so everyone has a turn at least one night.
Tack We have a very limited area for tack, so we will be using trailers as tack rooms for the weekend. They will be parked in the barn/paddock area. Let us know if you are willing to let your trailer be used. Welcoming Committee We would like a team of youth leaders who have attended camp previously to serve on a welcoming committee. Their responsibilities would be to help first year campers through the process of settling in on Thursday showing them where to park, where the rooms are, the way to the dining hall, etc. and to assist with check-in. Sign up on the registration form if you are interested. You must arrive by 10:00 a.m. Thursday to participate and you will receive a special t-shirt to wear on Thursday as part of the team. Sunday Show There will be a costume show plus a fun game show. Zip Line For those interested, the zip line or an alternate activity will be open ONLY Friday afternoon during free time. You must sign up and pay the additional cost of $5 per person. Only those (including adults) who have signed a release form and paid will be allowed to participate. The zip line is riding down a cable in a harness. You may watch for free!! Horse area will be patrolled at night by adults. Adults Those who stay are asked to help in 1-2 times. Please indicate on your registration form what you would like to do. We need adults to help with check-in and unloading (need to arrive by 10 am) Chaperones must be MN 4-H screened volunteers. Camp activities Canoeing, tubing, swimming (if we can get a lifeguard and it is warm enough!!), gym may be open (basketball, floor hockey, etc.). The zip line is available only for those who have signed up and paid the $5 fee. Pizza Buffet Thursday evening. This is included in the cost for those in the lodge/cabin. If any adults who camp would like pizza, there is a $7.00 charge. There will be no refunds if you are unable to be there. Email To save some postage costs, please CLEARLY PRINT your email address if you have one. Your registration can then be confirmed and information (such as instruction letter, directions to camp, health form, stall assignments, etc.) can be sent to you electronically. If you have not received information by May 24, please contact Lynn Watland (see contact information on next page). Permission to Leave Camp If it is necessary for a 4-H er to leave camp to attend a special activity or a trip to the Dairy Queen, a Day Departure Form must be completed and signed by the parent or guardian. REGISTRATION: Limited to 80 4-H'ers. Total amount of fees for camping, meals, insurance, and pizza are due at registration.
Cancellations will be accepted until April 30 with a full refund. After that, a refund is given (less $10 processing fee) only if another 4-H'er is available to fill in. Make checks payable to: University of Minnesota. QUESTIONS: For further information contact: Lynn Watland 27753 Co Rd 26 Browerville, MN 56438 218-894-2611 or cell phone at 218-296-1611 Email: glwatland@gmail.com (Please do not contact Camp Shamineau for information.) CONFIRMATION: By Email: These will be sent out beginning the first week in April By Mail: If you do not have email, please include a stamped, self-addressed envelope or postcard for confirmation. These will be sent out about the first week in April. 2018 Regents of the University of Minnesota. All rights reserved. University of Minnesota Extension is an equal opportunity educator and employer. In accordance with the Americans with Disabilities Act, this material is available in alternative formats upon request. Direct requests to 218-828-2276.
FAMILY REGISTRATION FORM 2018 CENTRAL AREA 4-H HORSE CAMP Return with total fees (payable to University of Minnesota) to: Lynn Watland, 27753 County Road 26, Browerville, MN 56438. 4-H MEMBERS (ENTER NAME YOU WISH TO BE CALLED BY) 4-H'ER NAME M F GRADE THIS YEAR AGE 6/7/18 4-H'ER NAME M F GRADE THIS YEAR AGE 6/7/18 4-H'ER NAME M F GRADE THIS YEAR AGE 6/7/18 ADDRESS CITY ZIP PHONE COUNTY EMAIL ADDRESS CELL PHONE (where enrolled in 4-H) #YEARS RIDING EXPERIENCE (please print clearly) ROOMMATE REQUESTS ZIP LINE (or alternate activity) Yes No Names of all those wish to participate in this event: Welcoming Committee (Youth leaders, previously attended camp) Check if this is your first time attending this camp ADULTS PARENT NAME(S) NAMES OF ADULTS STAYING BRINGING HORSE? ACCOMMODATIONS REQUESTED FOR ADULTS (lodge/cabin or campsite) ADULT MEALS IN DINING HALL (only if camping). Indicate day and quantity, such as Fri breakfast 2 TOTAL # OF HORSES BROUGHT BY FAMILY (Adults 4-H'ers )
ASSIGNMENT ADULTS WOULD LIKE: Patrol at night Games on Sunday Picnic on Sunday Chaperone in lodge/cabins (must be screened) Set up eve snacks Lifeguard Trail ride supervisor Maintain water bottles Nurse (RN LPN ) EMT Vet or Vet Tech Other Check-in & unloading (must arrive by 10 am) Willing to use trailer for tack Do any 4-H ers have any special needs or concerns, physical or otherwise, that staff should be aware of? (If so, please explain.) FEES 4-H ERS QUANTITY X PRICE = TOTAL FEES ADULTS 4-H'ers in lodge/cabin Thursday-Sunday x $185.00 = Zip line or alternate activity per person x $5.00 = Adults in lodge/cabin Thursday-Sunday x $185.00 = Adults Camping: (both Required) Camp Fee-- per person per night x $7.50 = Adult fee--per person for weekend) x $30.00 = Zip line or alternate activity - per person x $5.00 = Insurance - per adult x $2.00 = MEALS FOR THOSE NOT IN LODGE INDICATE QUANTITY (NO CHARGE FOR SUNDAY PICNIC) Breakfast x $7.00 = Noon x $7.00 = Supper x $7.00 = Pizza Buffet - Adults camping ONLY x $7.00/person = (included for those staying in lodge/cabin) Total Amount Paid: ------------------------------------------------------- INSURANCE VERIFICATION (to be completed by county staff): I hereby certify that is covered by the 4-H insurance through County. Insurance Company Name Policy Number 4-H Program Coordinator Signature Date 2018 Regents of the University of Minnesota. All rights reserved. University of Minnesota Extension is an equal opportunity educator and employer. In accordance with the Americans with Disabilities Act, this material is available in alternative formats upon request. Direct requests to 218-828-2276.
ADULT HEALTH FORM Event: 4-H Horse Camp Adult Name: 4-H County: Date: HEALTH INFORMATION Please be accurate yet concise. In an emergency, this may be the only immediate source of information. Do you have any health diagnosis that is important for program staff to know in order to maximize participation and ensure safety and well-being? Health diagnosis details/ explanations and suggested accommodations. No, I do not have any relevant health diagnosis. Yes, a physical disability, a learning disability, behavioral disorder, and/or mental health diagnosis. Do you have any specific dietary needs? Dietary needs details/explanation. No special food needs or requests. Yes, food allergies or restrictions (e.g. peanuts, gluten-free) or food preferences (e.g. vegetarian). Do you have any allergies or reactions to drugs or things in nature? If so, please describe. Do you have any conditions requiring medication? Medication details/explanation. No medications are needed. Yes, and assistance is needed with medications. Yes, and I am capable of self-administering medications. Is your Tetanus immunization current? No Yes Not sure Date of last Tetanus shot (month/year). Leave Blank if not current or unknown. Do you have any other health related conditions? EMERGENCY CONTACT INFORMATION Contact name 1: Primary (best to call) phone number: Alternate phone number: Relationship to volunteer: Contact name 2: Primary (best to call) phone number: Alternate phone number: Relationship to volunteer: 2018 Regents of the University of Minnesota. University of Minnesota Extension is an equal opportunity educator and employer. In accordance with the Americans with Disabilities Act, this publication/material is available in alternative formats upon request. Direct requests to 218-828-2276.
MINNESOTA 4-H EVENT PARTICIPATION AGREEMENT & COMPLETE WAIVER AND RELEASE (FOR ADULTS) I, (hereinafter I, my and me ), register for participation in 4-H Horse Camp conducted at Camp Shamineau June 7-10, 2018 (the Program ). In consideration of such participation, I agree as follows: 1. Risks. I know the Program could result in risks of harm, including severe personal injury, disability, death or property loss or damage ( Risks ). The University has no control over factors that may influence the Risks. I am knowledgeable in the activities involved in the Program, and have no medical reason why participation is not advised. 2. Release. I voluntarily and knowingly accept full responsibility for encountering all Risks, known and unknown. On behalf of myself, my minor child, my heirs, next of kin and anyone else who might claim through me, on my behalf, or who might have a claim arising out of, related to or based upon any disability, death or loss or damage to person or property I may experience as a result of the Program, I expressly forever release, indemnify and hold harmless Regents of the University of Minnesota, Extension, its directors, employees, volunteers and leaders; collaborators, sponsors, Program organizers, promoters and each of their agents, representatives, successors and assigns, and all other persons associated with the Program ( Releasees ) from any and all loss, cost, expense or other damage of any kind, including but not limited to insurance subrogation and attorney s fees (together and singly, claims ). THIS PROMISE APPLIES EVEN TO CLAIMS BASED IN WHOLE OR IN PART ON RELEASEE S NEGLIGENCE AND/OR GROSS NEGLIGENCE TO THE EXTENT PERMITTED BY LAW. 3. Emergency. Program staff may render first aid and/or obtain medical treatment s/he deems necessary. I will be financially responsible for all costs incurred thereby, regardless of insurance coverage. 4. Photo Release. I grant Releasees full permission to use images, recordings or any other record of me while participating in the Program in any medium. I agree that my name and identity may be revealed therein or by descriptive text or commentary. 5. General. I will comply with stated and customary rules for participation. If I observe any unusual or significant hazard, I will remove myself from participation and bring the hazard to the attention of the nearest official immediately. Program staff may terminate any participation due to inappropriate conduct. The registration fee is non-refundable and non-transferable. 6. Jurisdiction. The laws of the State of Minnesota govern validity, construction and enforceability of this Agreement, without giving effect to its conflict of laws principles. All suits, actions, claims and causes of action relating thereto shall be in the State Courts in Hennepin County, Minnesota. I HAVE READ THIS LEGALLY BINDING DOCUMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND AGREE TO BE BOUND BY IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. THIS DOCUMENT MAY BE ELECTRONICALLY SIGNED. A PHOTOCOPY OR FACSIMILE WILL BE AS VALID AS AN ORIGINALLY SIGNED DOCUMENT. Name of Adult Participant: Signature: Date: Created 1/2016 2018 Regents of the University of Minnesota. All rights reserved. University of Minnesota Extension is an equal opportunity educator and employer. In accordance with the Americans with Disabilities Act, this material is available in alternative formats upon request. Direct requests to 612-624-2116.
Shamineau Ministries Acknowledgement and Assumption of Risk, Medical Treatment and Media Release (Minors or Student) Required for Zip Line or other Activity Student covered by this Release (print first and last name: Acknowledgement of Risk We have chosen to attend the Shamineau Ministries (Camp Shamineau, Shamineau Adventures, Shamineau Ranch and Rock Ridge Camp) programs in part because of the activities they offer. I understand and acknowledge that participation in the activities offered by Shamineau Ministries (including but not limited to rock climbing, hiking, snowshoeing, crosscountry skiing, high and low ropes course elements, riflery, horseback riding, mountain boarding, swimming, the blob, skateboarding and roller blading, climbing the ice tower or artificial indoor climbing wall) entails both known and unanticipated risks of harm which could results in both physical or emotional injury, paralysis, death or damage to the participant, to property, or to third parties. I understand and acknowledge that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I further understand and acknowledge that the risk of harm inherent in these activities may be increased beyond the control of Shamineau Ministries, including but not limited to the weather and elements, equipment manufacturer s malfunction and a participant s fitness and abilities. Hold Harmless In consideration of my child s participation in Shamineau Ministries programs and activities, I hereby release and discharge, indemnify and hold harmless Shamineau Ministries, its officers, directors, employees, agents, volunteers and assigns from any and all liability, claims, demands, costs and expenses, and causes of action whatsoever arising out of or in any way connected with any property loss and/or bodily injury including death and/or disability arising from my own or my family members participation in Shamineau Ministries activities. Consent to Arrange Medical Treatment In the event of an illness, injury or emergency, I hereby authorize Shamineau Ministries staff to secure proper medical treatment for myself or my family members including transportation and hospitalization, if necessary. Media Release I authorize Shamineau Ministries to use photos or videos taken of myself or my family members at camp for Shamineau Ministries promotional purposes. At no time will camp photos be used by unrelated organizations. Parent or Guardian: Signature Date