January 4, Sincerely, Donna Fox Extension Specialist for 4-H Youth Development. Dear 4-H Shooting Sports Enthusiast,

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1 January 4, 2019 Dear 4-H Shooting Sports Enthusiast, 4-H Shooting Sports State 4-H Department 212 Scovell Hall Lexington, KY (859) Fax: (859) Enclosed are the details for the H State Shooting Sports Camp which will be held April 3-6, 2019 at the Lake Cumberland 4-H Camp. This is a statewide camp open to all interested youth ages 9 to 13. The cost of the camp is $ One check per county should be mailed with all forms to the State 4-H Office, Attn. Shooting Sports Specialist. Online Registration and Payment is due to State 4-H Office Postmarked by March 1 st. Late fees will apply. All checks must be made payable to the Kentucky 4-H Foundation. Enrollment is limited to the first 140 campers statewide. Again this year there is an online registration system. Whoever enters participants online must have a UK LinkBlue account. So registration must be done at the local County Extension Office. All forms and copies of the completed registration forms must be postmarked by deadline of March 1st and mailed to the State 4-H Office, Attn. Shooting Sports Specialist. Certified youth instructors have been recruited by the planning committee and will present the classes and range work. Each camper will learn responsible, safe use of firearms and how to shoot in the six disciplines of the program: rifle, trap, archery, black powder, hunter challenge and pistol. Additional program highlights will include night hikes, nature events, campfires, crafts, wild animals program, etc. If campers do not have their Orange Hunter Safety Card, the opportunity will be provided at camp. The camp requires each county to send at least one adult per five campers. The adults must be approved by their county s 4-H Youth Protection Program which requires additional, separate paperwork. If you have one camper or five campers, your county will need at least one adult. If you have six campers, you need two paying adults. These adults must complete the same paperwork, pay the same fees, stay on the campgrounds for the duration of the camp, sleep in the cabins AND attend class rotation with their campers. The state planning committee has agreed that there will be no exceptions to this rule. If counties are going to share leaders, this must be arranged by the individual counties and noted on the camper s forms. It is the responsibility of the counties to notify us of the sharing arrangement. The camp committee has also decided that only those Teens that are selected by the lead camp discipline instructors and approved by the planning committee will be allowed to attend the camp. We have a great program planned for the upcoming Shooting Sports Camp. Please let your youth and leaders know about the camp as soon as possible. There will be no exceptions to the deadline. To be registered, the following completed items must be submitted to the State 4-H Office, Attn. Shooting Sports Specialist by March 1. One check per county for $140/person payable to Kentucky 4-H Foundation Complete online registration, and it must match registration forms. Appropriate number of adult chaperones. Completed registration form WITH parent/guardian signatures. Photocopy of both sides of health insurance card(s). Sincerely, Donna Fox Extension Specialist for 4-H Youth Development

4-H SHOOTING SPORTS CAMP WHEN: Wednesday, April 3 - Saturday, April 6, 2019 WHERE: Lake Cumberland 4-H Camp, Jabez, Kentucky WHO: Youth 9-13 years of age For every 5 campers or a portion thereof, a

Campers are responsible for transportation; Your County Extension Office may try to arrange car pooling. BRING: Sleeping bag, blankets, personal items, toiletries, rain gear, and warm casual clothes.

Certified instructors will be present for classes and range work. Each camper will learn responsible and safe use of firearms and how to shoot in the six disciplines of the shooting sports program.

2 4-H SHOOTING SPORTS CAMP WHEN: Wednesday, April 3 - Saturday, April 6, 2019 WHERE: Lake Cumberland 4-H Camp, Jabez, Kentucky WHO: Youth 9-13 years of age For every 5 campers or a portion thereof, a county MUST have one adult. No exceptions. HOW MUCH: $140 includes all expenses at camp and crafts. Campers are responsible for transportation; Your County Extension Office may try to arrange car pooling. BRING: Sleeping bag, blankets, personal items, toiletries, rain gear, and warm casual clothes. Each camper must bring their own ear and eye protection. DO NOT BRING ANY GUNS, ARCHERY EQUIPMENT OR AMMUNITION. They will be provided. Certified instructors will be present for classes and range work. Each camper will learn responsible and safe use of firearms and how to shoot in the six disciplines of the shooting sports program. They are: * RIFLE * TRAP * ARCHERY * PISTOL * BLACK POWDER * HUNTER CHALLENGE Additional program highlights for the week that you will be a part of: Night Hikes Wild Animals Program Night Programs Hunter Education Heritage Foods Campfires Survival Skills Nature Crafts Animal Tracks REGISTRATION DEADLINE: March 1, Space is limited to the first 140 applicants statewide because of the small class sizes. Enrollment is on a first come, first serve basis. Meeting the registration deadline is very important as well as having enough adult chaperones. Adult Chaperones must complete packet and have completed the Client Protection Process. The final camper forms and instructions will be ed to County Offices after March 16th; these forms will be sent to eligible campers after their fees are paid. If you have questions, please contact your County Extension Office. If you have any questions, please contact Donna Fox at (859) or dfox@uky.edu. The forms will be available on the State 4-H Webpage starting on January 4, 2019.

Kentucky 4-H Camping Shooting Sports Camp 2019 Camp Participant Registration Check One: Camper.

Yes - # years: No School & Grade Entering: County: Gender Identity: Male Female Completed Client Protection Process?

Participant s Home Address: Street City, State, Zip Participant s Race: White Black Asian American Indian Hawaiian Cannot be determined Other

3 Kentucky 4-H Camping Shooting Sports Camp 2019 Camp Participant Registration Check One: Camper. Teen Adult Volunteer Adult Instructor Last Name: Legal First Name: Middle Name: Preferred Name: Attended camp before? Yes - # years: No School & Grade Entering: County: Gender Identity: Male Female Completed Client Protection Process? (Adults Only) Yes No Does Participant have their Hunter s Education Card? Yes No Birthdate: / / Age on 1st day of camp? Participant s Home Address: Street City, State, Zip Participant s Race: White Black Asian American Indian Hawaiian Cannot be determined Other Participant s Ethnicity: Hispanic Non-Hispanic Legal Parent/Guardian #1 Full Name: Address: Cell/Home Number: Legal Parent/Guardian #2 Full Name: Address: Cell/Home Number: Emergency Contact Full Name: Relationship to Participant: Cell/Home Number: Physician Name: Physician Phone Number:

4 PARTICIPANT NAME: County: Is the camp participant up-to-date on immunizations as outlined by Kentucky law required for enrollment in public, private, or home school, based upon the grade the participant will be enrolled for the upcoming school year? YES NO (If marked NO, check with your 4-H agent for a waiver of liability form.) Does the participant have health insurance coverage? YES (Attach a copy front and back of the insurance card in the boxes below. Use tape, DO NOT staple.) NO (No worries! Camp provides an excess medical insurance coverage in the event of injuries or illnesses.) FRONT OF INSURANCE CARD BACK OF INSURANCE CARD Had any recent injury, illness, or infectious disease? Have a chronic or recurring illness/condition? Ever been hospitalized? Ever had surgery? Have frequent headaches? Ever been knocked unconscious? Wear glasses, contacts, or protective eyewear? Ever had frequent ear infections? Ever passed out, or been dizzy during exercise? Ever had chest pain during exercise? Had problems with sleepwalking? Ever had seizures? Ever had emotional difficulties? Ever had an eating disorder? YES NO Ever had high blood pressure? Ever been diagnosed with a heart murmur? Ever had back problems? Ever had problems with joints, knees, or ankles? Have an orthodontic appliance brought to camp? Have any skin problems (rash, acne)? If female, any abnormal menstrual history? Had problems with diarrhea or constipation? Had mononucleosis in the past 12 months? Have diabetes? Have asthma? Have a history of bed wetting? Have severe allergies? Carry an epi-pen or inhaler? YES NO Are there any specific behaviors, medical needs, dietary needs, accommodations, or information that the staff should be made aware of to provide a better camp experience for the participant? (Provide details for any questions above marked YES): Are there accommodations during the school year that your child requires we should plan for at camp? (i.e. accommodations for 504 and IEP Plan):

5 PARTICIPANT NAME: COUNTY: AUTHORIZATIONS/RELEASES This is a legal document. You must read and understand it before signing it. MEDIA RELEASE: I grant the Kentucky 4-H Program and the University of Kentucky, Kentucky State University, and persons acting through them, the right to use, reproduce, assign, and/or distribute photographs, films, videotapes, and sound recordings of my minor child without compensation for use in promotion/advertising, educational publications, electronic publishing, and personal memorabilia. Participant names may be published. Yes. I grant permission for media releases. No. I do not grant permission for media releases. Pick-up Release: It is my responsibility to arrange to pick up my child/children upon return from camp. There will be no exceptions to this policy regardless of relationship to the child. Please inform everyone approved by you on this release that he/she must present a driver s license or photo ID before the child will be released. Parents, Guardians, and Emergency Contacts listed on page 1 and 2 are automatically assumed to have pick up authorization. In addition to the parents/guardians listed on page 1, the following individuals are granted permission to pick up my child: NAME: RELATIONSHIP Phone/Cell# NAME: RELATIONSHIP Phone/Cell# NAME: RELATIONSHIP Phone/Cell# CONSENT TO TREAT: The health history reported on page one and two are correct and complete to the best of my knowledge. I hereby permit the camp to provide routine health care, administer over the counter medication, assist in administering participant s prescription medications as needed, and seek emergency medical treatment including ordering x-rays and routine tests. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I permit the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby permit the physician selected by the camp to secure and administer treatment, including trips off camp property. CODE OF CONDUCT: I have read and discussed the Camp Code of Conduct with my participant. We (parent/guardian and participant) understand and agree to comply with the guidelines. Violations may result in loss of privileges, removal from camp with no refund, assessment of a damage fee for which I will be responsible for paying, and/or ineligibility to participate in future 4-H events. An incident report will be completed for major violations. ASSUMPTION OF RISK, RELEASE OF LIABILITY, and PERMISSION TO PARTICIPATE: I acknowledge that there are certain risks, hazards, and dangers, including the risk of physical injury, disability, or death and risk of loss of use or damage to my personal property as a result of allowing participation in the camping program. 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 the use of equipment, materials, or facilities recommended by the University of Kentucky; environmental conditions; from the acts or omissions of others; or from the unavailability of immediate and adequate emergency medical care. I understand that the University of Kentucky does not guarantee the personal health or safety of participants, nor does it protect against the risk of loss of personal property. In consideration for allowing my child to participate in the camping program, I do hereby release Kentucky 4-H Camp, the University of Kentucky, Kentucky State University, and its members, trustees, officers, employees, independent contractors, volunteers and extension staff from any and all liability, damages, cost, and expenses arising out of or relating to bodily or psychological injury, loss of life, or personal property that may occur as a result of participating in the camping program. I understand that my child s participation in the Kentucky 4-H Summer Camping Program is based on the challenge by choice philosophy. I recognize that programs are designed to use experiential, engaging teaching techniques, but that my child s participation is purely voluntary, always, and my child will choose his or her level of participation in any activity (including, but not limited to: high ropes, rock climbing, low challenge elements, rifles, archery, trap shooting, horses, and cave exploration). Participant Signature: Date: Parent/Guardian Signature: Date:

6 Kentucky 4-H Camp Medication Form 2019 Participant s Name County Sleeping Facility (e.g., cabin #2, yurt #1) Age Weight Name of Medicine Dosage Time of Medicine (Check all that apply) Breakfast Lunch Dinner Bedtime Other Notes (e.g., as needed, take w/ food) DIRECTIONS: Place the following items in a clear bag: (1) medications, (2) this completed form, and (3) a recent photo of the participant. On the outside of the bag write (with a permanent marker) the participant s name, county, and sleeping facility. OFFICE USE ONLY Sunday Monday Tuesday Wednesday Thursday Friday Saturday HCP Review Stamp Breakfast Lunch Dinner Bedtime Other

7 Kentucky 4-H Camping Medication Policy - Shooting Sports Camp Medications should be submitted to the Camp EMT in a clear Ziploc bag at check-in: o o On the outside of the bag using a permanent marker: (1) the name of the participant, (2) county name, and (3) sleeping facility (e.g., cabin #4, boy s outpost, yurt #2). Inside the bag should contain: (1) all medications, (2) a completed medicine form, and (3) a recent photograph of the participant. All prescription medication MUST be in its original container. This is a state law. Parents/Guardians should send only the number of pills the camper will need for the camp session. Medication may only be given to the person whose name is on the prescription medication container. Siblings cannot share medications unless both names are on the container. If a participant s prescription has changed and the directions on the medication bottle are different, the parent/guardian must include a note from the physician (on his/her letterhead) with the correct instructions for taking the medication. The medication cannot be given without the physician s note. If a participant must keep an inhaler or epi pen on their person during the camping session, the parent should provide a backpack or other item in which to securely store them while participating in activities. Camp cannot be responsible for lost inhalers or epi pens. For participants who require special medical treatments, IV s, blood sugar tests, insulin, etc. a trained assistant or the camper will be responsible for this care. Camp s health care provider is not allowed to administer these special treatments. Camp provides a variety of over the counter medications for general use, (e.g., cough syrup, Benadryl, sting ease). If a parent/guardian wants aspirin given to their child, it must be sent with the child. Camp does not administer aspirin to anyone less than 18 years of age. If the parent/guardian wishes to send a specific brand name over the counter medication, they may do so. A medication form must be completed for the camper for this medication. Revised 08/27/2018

Kentucky 4-H Camping 2019

Kentucky 4-H Camping 2019 Camp Participant Registration Camper/Teen (Ages 5 to 17) Last Name: Legal First Name: Middle Name: Preferred Name: Attended camp before? Yes - # years: No School & Grade Entering: