University of Illinois Extension, Kane County 535 S. Randall Rd. St. Charles, IL 60174

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1 Serving DuPage, Kane & Kendall Counties 535 S. Randall Rd., St. Charles, IL Phone 630/ FAX 630/ October 2017 For those interested in continuing or joining the 4-H Shooting Sports program in Kane County, we currently offer Archery. Two other disciplines Outdoor Skills and Air Rifles offered with our program are conducted in Kendall County. Details about all disciplines can be found on our website. ARCHERY is scheduled to begin on November 12, 2017, and continue on selected Sunday afternoons through May 13, Classes are held in Robinson Hall on the Kane County Fairgrounds, from 4:00 to 6:00 p.m. A schedule of dates is attached. The instructor for this program is Shawn Pickett. To enroll in any of these disciplines, you must go to: On that site, you will create a 4-H family profile. To enroll in Shooting Sports Archery, select Kane County and choose Archery. To Enroll in Air Rifles or Outdoor Skills, you will need to enroll in Kendall County and choose Air Rifles and/or Outdoor Skills as the club for each of the youth in your family that would like to participate. The letter and health form can be found at: The program fee for all shootings sports program is $20. If you are only enrolling in 4-H Shooting Sports Archery, please pay the program fee to Kane County. To enroll only in Air Rifles or Outdoor Skills, pay the program fee to Kendall County. You can pay your program fee with a credit card in 4-H Online checks are also acceptable and should be made out the University of Illinois Extension and mailed to the Kane County Extension Office. There is a materials fee for the program as well $25 for archery, air rifles and outdoor skills. The materials fee is payable by check to the Kendall County 4-H Shooting Sports and should be mailed to: University of Illinois Extension, Kane County 535 S. Randall Rd. St. Charles, IL In order to complete registration, all youth participants must complete the Youth Emergency Medical Form and the 4-H Assumption of Risk and Release of Liability. These forms are attached to this letter and must be received PRIOR to the start of the first sessions. Registration will not be complete without these forms, 4-H Online registration and payment of all fees. If you are in one shooting sports program, and want to add a second, you will pay only the $25 materials fee for the second program. Registration for Shooting Sports groups are taken all year long and must be done online with the materials fee taken to the first meeting. Please register each child you wish to participate in each discipline. A couple of other things to note For all sessions, youth must have safety glasses. All other equipment for the sessions will be provided. The equipment we will be using for our program is from a generous grant made available by the NRA Foundation. In addition, a parent or guardian must be present for the sessions with their child/children.

2 We are looking forward to another successful year of the 4-H Shooting Sports program in DuPage, Kane & Kendall Counties! Sincerely, Doris Braddock Program Coordinator 4-H Youth Development University of Illinois Kane County Extension

3 University of Illinois Extension/4-H Youth Development Unit 5 DuPage, Kane, Kendall Counties Shooting Sports (Archery) TENTATIVE Schedule When: Time: Where: One Sunday per month (see dates below) 4-6 p.m. Kane County Fairgrounds, St. Charles Robinson Hall/4-H Exhibit Building Volunteer Instructor: address: Phone: Shawn Pickett papap45@aol.com (cell) 2017 November 12 December January 7 February 11 March 18 April 15 May 13 (Mother s Day)

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5 Club: 4-H Shooting Sports - Archery 4-H ASSUMPTION OF RISK AND RELEASE FROM LIABILITY Youth s name: (printed) Agreement to Follow Behavior Guidelines and Safety Polices: I agree that my child and I will fully discuss, and my child will adhere to, the Youth Behavior Guidelines, Code of Conduct for 4-H Events and any other safety policies provided to me by 4-H. I understand and agree that 4-H staff have the authority to remove my child from an activity if the staff determines that my child s behavior or actions pose a threat to other participants. Acknowledgement and Assumption of Risks: I understand that 4-H provides for children a wide array of high-risk, medium-risk and low-risk activities, including, but not limited to: horse- and pony-riding practices and competitions, shooting sports practices and competitions, 4-H fairs and competitions, day and overnight camps, field trips (some of which include overnight stays), project workshops and 4-H club meetings. I understand and acknowledge that participation in 4-H activities carry certain inherent risks and hazards, including, but not limited to, accidents from shooting sports and equine activities, transportation accidents, the unavailability of immediate or adequate emergency care, weather-related other environmental hazards, slips and falls, pinches, scrapes, sun burns, twists and jolts. I understand that these inherent risks and hazards might result in the physical injury (such as scratches, bruises, sprains, lacerations, fractures, concussions), disability (such as paralysis or other severely debilitating injuries) or death of my child and the loss of or damage to my child s personal property. I acknowledge many of these risks cannot fully be eliminated regardless of the care taken to avoid them. I acknowledge that the University of Illinois neither guarantees the personal health or safety of my child nor of his/her personal property. I hereby assert I fully and knowingly assume such risks, hazards and dangers, known or unknown, of my child s participation in the 4-H Program and accept all responsibility for losses, costs, injuries and damage my child, my property, or my child s property incurs as a result of such participation. Consent to Treatment: In the event that my child requires medical care while participating in a 4-H activity and no designated emergency contact (including myself) can be reached, I grant to 4-H the authority to consent to all medical and/or dental care deemed necessary and to provide to medical personnel the UI Extension 4-H Program Youth Emergency Medical Information form with all pertinent medical and health information about my child. This consent expires when my designated emergency contact can be reached. I understand I, and not the University of Illinois, will be solely responsible for paying any bills, co-payments and deductibles associated with such care and treatment. Waiver, Indemnification and Hold Harmless: In consideration of my child s participation in this 4-H activity, I do hereby release, waive, discharge, and covenant not to sue the Board of Trustees of the University of Illinois and its respective officers, employees, and agents for any and all claims including those which result in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in the 4-H activities on behalf of myself and my child, heirs, personal representatives or assigns. I agree to INDEMNIFY AND HOLD the Board of Trustees of the University of Illinois HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney s fees, brought as a result of my child s involvement in the 4-H activity and to reimburse it for any such expenses incurred. Acknowledgment of Understanding: I have read this entire document, fully understand its terms, and understand that, by signing it, I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. HORSE ACTIVITY: Each participant engaging in equine activities expressly assumes the risk of engaging in and legal responsibility for injury, loss or damage to person or property resulting from engaging in equine activities. SHOOTING SPORTS: Individuals removed from any 4-H activity for behavior outlined in Category 1 or 2 of the University of Illinois Extension, Code of Conduct for 4-H Events and Activities may not be allowed to participate in future shooting activities. Signature of Parent of Minor (under 18) Date Signature of Participant Date Approved as to Legal Form by the Office of University Counsel LTI 8/2016 University of Illinois U.S. Department of Agriculture Local Extension Councils Cooperating University of Illinois Extension provides equal opportunities in programs and employment.

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7 CONFIDENTIAL UNIVERSITY OF ILLINOIS EXTENSION 4-H PROGRAM YOUTH EMERGENCY MEDICAL INFORMATION EVENT: Unit 5, DKK 4-H Shooting Sports, PARTICIPANT'S NAME: Address: Street City State/Zip Code Age: Sex: Date of Birth: / / PARENT/GUARDIAN/OTHER EMERGENCY CONTACTS: Name: _ Relationship Home Phone: _( ) - Work Phone: _( ) - Cell Phone: _( ) - Address: Street City State/Zip Code Name: _ Relationship Home Phone: _( ) - Work Phone: _( ) - Cell Phone: _( ) - Address: Street City State/Zip Code HEALTH INFORMATION STATEMENT Check below any information you feel staff and/or volunteers may need, to maximize the safety and the well being of the exhibitor or staff member. To the right of the condition statement is space for more information relating to the condition checked. Please be specific. In case of emergency, this health information may be the only source of accurate, important information. [ ] Nervous or Mental (epilepsy, emotional stress, convulsions) [ ] Lung Disease (asthma, persistent cough, tuberculosis) [ ] Disease of Heart or Blood Vessels, Increased or Abnormal Blood Pressure [ ] Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever) [ ] Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis) [ ] Arthritis, Diabetes, Kidney or Bladder Disease [ ] Hay Fever or Allergies [ ] Allergy to Medicines (including penicillin, tetanus) [ ] Impaired Sight or Hearing, Chronic Ear Infections

8 CONFIDENTIAL [ ] Recent Surgical Operation, Accidents or Injuries [ ] Any Infectious Disease [ ] Skin Disease [ ] Allergy to Foods [ ] Currently taking Medicines (list names & doses) [ ] Medication that needs refrigeration [ ] Under on-going care of a Physician (NAME & PHONE #) for chronic or recurring problem [ ] Do you wear glasses? YES[ ] NO [ ] SOMETIMES[ ] [ ] Do you wear contact lenses? YES [ ] NO[ ] SOMETIMES [ ] [ ] Date of last TETANUS BOOSTER [ ] Date of last FLU SHOT [ ] Significant Orthopedic and/or Neuromuscular Impairment (e.g. loss of limb, spinal cord injury) Primary Care Physician: Clinic/Hospital Affiliation: City: State: Phone: _( ) - Health Insurance Provider: Owner's Name: ID/Policy Number: Medical Privacy Statement: It is the policy of University of Illinois Extension 4-H Youth Development Programs to keep any medical information it may have regarding 4-H Youth Development program participants confidential. However, there may be time in which such medical information will be needed and may need to be shared with others. Examples of sharing might include: providing information to medical personnel in the event of an emergency so that a youth may be treated; providing information to Extension staff or volunteers who are coordinating specific events in the case of a request for reasonable accommodation; and providing information to chaperones or host families who are responsible for the health and safety of program participants at a specific event. Except in the case of emergency, prior to sharing any medical information, it may have with those external to the University, Extension, or 4-H, every effort will be made to get the permission of the program participant or parent or guardian. As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given. I further understand that in case of serious illness/injury, I will be notified. However, if it is impossible to contact me, I give my permission for emergency treatment, x-ray or surgery, as recommended by an attending physician. I also understand that any accident insurance in effect (IF PROVIDED) for the event does not cover pre-existing conditions or selfinflicted injuries. SIGNED: DATE: Parent or Guardian Revised 7/03 Issued in furtherance of Cooperative Extension Work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, D. R. Campion, Director, University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension provides equal opportunities in programs and employment. *The 4-H Name and Emblem are Protected Under 18 U.S.C. 707.