Teen Leadership Camp July 30-August 1

Transcription

1 2012 Registration Deadline March July 2, Teen Leadership Camp July 30-August 1 Swannanoa 4-H Camp Swannanoa, North Carolina Name: Age: Gender: F M DOB: Address: County: Grade: City: State: Zip: Home Phone: Work Phone: Cell: Allergies: Dietary Needs: Parent(s)/Guardian(s): CIRCLE YOUR SHIRT SIZE Shirt Sizes: S M L XL XXL XXXL One shirt per registered youth or adult is included in your registration fee. If you would like to buy an extra t-shirt let your county 4-H office know when registering. Cost for extra t-shirts is $10.00 each. AGES: Participants must be 12 years old by January 1, 2012 COST $150 (Registrations cancelled by July 13 th will receive a 50% refund. Cancellations after July 13 th will not receive a refund, however same-gender substitutions can be made.) Make Checks Payable To: McDowell County 4-H Return this as well as the following forms to your County 4-H Program/North Carolina Cooperative Extension office in your county. Must be return by July 1st. Forms to include: NC 4-H Medical Release Form (must be notarized) NC 4-H Media Release Form Nantahala Outdoor Center Release of Liability and Assumption of Risk Agreement (signed by parent) Please initial: I understand that compliance with the NC 4-H Code of Conduct and Disciplinary Procedure is a condition of participation in 4-H events. Collected in compliance with federal requirements intended to ensure equitable program administration and availability. Race or Ethnicity: White or Caucasian Black or African-American Asian Native American or Alaskan Native Native Hawaiian or Pacific Islander Hispanic or Latino Other Fun Things To Do: *Fun Shops *Whitewater Rafting *Food and Fellowship *Camp Activities **Camp is limited to 40 youth.** Make sure to sign up soon!! For questions or more information please contact Chad Ray at or chad_ray@ncsu.edu.

2 4-H MEDICAL INFORMATION AND INFORMED CONSENT FOR TREATMENT FOR NC 4-H SPONSORED EVENTS PLEASE READ AND COMPLETE THE FOLLOWING FORM. THIS FORM MUST BE PRESENTED AT THE OFFICIAL REGISTRATION FOR THE 4-H SPONSORED EVENT BEING ATTENDED. I. Medical Information Known allergies to foods, drugs, insect stings or bites, etc: Special medical concerns or conditions that event supervisors should know about, including contagious illnesses, epilepsy, asthma, diabetes, previous injuries to bones/joints, etc.: List special dietary needs: Medications currently being taken (name of medication, dose, and frequency): Family Physician: Name Phone # ( ) Address II. Insurance Information The 4-H program purchases insurance for youth participants for many sponsored events. In some cases, this coverage will not pay for some medical expenses and it may be necessary to bill the family or your insurance company. Health Insurance Company: Health Insurance Policy # : Company Address: Phone Company Telephone Number ( ) If you are a person with a disability and desire any assistive devices, services or other accommodations to participate in this activity, please contact [name, office] at [phone number/tty] during business hours of 8 a.m. and 5 p.m. to discuss accommodations at least [hours/days] prior to the activity. III. Signatures Acknowledging Parts I, II, and III Parent's/Guardian's signature: Date: Participant's Signature: Date: Parent/Guardian telephone #: Home Work 1of 2 Must be completed each year by 4-H er and Parent/Guardian. If health history changes within that year, it is the 4- H er & Parent/Guardian s responsibility for updating information. Approved as of 3/02/06

3 IV. Informed Consent In the event that a participant needs minor medical care from 4-H or more significant medical care from a qualified heal care provider, including in rare cases possible hospitalization and/or surgery, the parent/guardian is asked to sign the informed consent form below. In case of serious medical condition, 4-H will make every effort to notify the parents, but the first priority may be providing care to the participant. Authorization to Consent to Health Care for Minor: I,, of County, am the custodial parent having legal custody of, a minor child, age, born. I authorize any adult(s) acting as agents (including official volunteers) or employees of the 4-H program and in whose care the minor child has been entrusted, to do any acts which may be necessary or proper to provide for the health care of the minor child, including, but not limited to, the power (i) to provide for such health care at any hospital or other institution, or the employing of any physician, dentist, nurse, or other person for such health care, and (ii) to consent to and authorize any health care, including administration of anesthesia, X-ray examination, performance of operations, and other procedures by physicians, dentists, and other medical personnel except the withholding or withdrawal of life sustaining procedures. This consent shall be effective for one year from the date of the execution. Custodial Parent Signature: Date STATE OF NORTH CAROLINA COUNTY OF On this day of, 20, personally appeared before me the said named,, to me known and known to me to be the person described in and who executed the foregoing instrument and he (or she) acknowledged that he (or she) executed the same and being duly sworn by me, made oath that the statements in the foregoing instrument are true. My commission expires, 20. Notary Public (OFFICIAL SEAL) 2of 2 Must be completed each year by 4-H er and Parent/Guardian. If health history changes within that year, it is the 4- H er & Parent/Guardian s responsibility for updating information. Approved as of 3/02/06

4 North Carolina 4-H and Buncombe County 4-H Photographic, Video, and Audio Optional Publicity Release I do or do NOT give permission to North Carolina State University, through its Cooperative Extension program for North Carolina 4-H, and Buncombe County Extension staff, to take photographs and/or record video and/or audio or otherwise record images and likenesses of me and/or my property and to use these for 4-H Youth Development nonprofit educational, promotional, and/or marketing materials. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I expressly release North Carolina State University, its agents, employees, licensees and assigns from and any and all claims which I may have for invasion of privacy, right of publicity, defamation, copyright infringement, or any other causes of action arising out of the use, adaptation, reproduction, distribution, broadcast or exhibition of such recordings of my image, voice, or likeness. I understand this permission is entirely optional, and that participants who do not give permission will remain eligible for 4-H services, benefits, and privileges the same as those who do give permission. Participant Name (please print): Participant Signature: Date: If individual is under the age of 18, consent of the legal parent or guardian is needed. Parent/Guardian signature: Parent/Guardian name (please print): 1of 1 Approved as of 3/02/06

5 Wildwater's Nantahala Gorge Adventure Center PO Box 309, Long Creek, SC (864) FAX: (864) (Wildwater information only) Date Trip Time Group Name WAIVER AND RELEASE OF LIABILITY PLEASE READ CAREFULLY In consideration of Wildwater, Ltd. furnishing services and/or equipment to enable me to participate in whitewater paddling, Jeep Tours, transportation and other activities, I agree as follows: I fully understand and acknowledge that outdoor recreational activities have: (a) inherent risks, dangers and hazards and such exists in my use of paddling equipment and my participation in paddling activities and related activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability; (c) these risks and dangers may be caused by the negligence of the owner, employees, officers or agents of the United States of America, United States Forest Service, Duke Energy, Great Smoky Mountains Railroad, and Wildwater, Ltd.; the negligence of the participants, the negligence of others, accidents, breaches of contract, the forces of nature or other causes. Risks and dangers may arise from foreseeable or unforeseeable causes including, but not limited to, staff decision making, including that staff may misjudge terrain, weather, transportation, trail or river route location, and water level, risks of falling out of or drowning while in a raft, canoe or kayak and such other risks and hazards and dangers that are integral to recreational activities that take place in a wilderness, outdoor or recreational environment; and (d) and by my participation in these activities and/or use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages, whether caused in whole or in part by the negligence or other conduct of the owners, agents, officers, or employees of the United States of America, United States Forest Service, Duke Energy, Great Smoky Mountains Railroad, and Wildwater, Ltd., or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify the United States of America, United States Forest Service, Duke Energy, Great Smoky Mountains Railroad, and Wildwater, Ltd. and its owners, agents, officers and employees from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of paddling equipment or my participation in paddling activities, transportation, and related activities. I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the owners, agents, officers or employees of the United States of America, United States Forest Service, Duke Energy, Great Smoky Mountains Railroad, and Wildwater, Ltd. I hereby authorize Wildwater Ltd. and its photographic agents to take and utilize photographs of me for the purpose of sale, promotion and advertising. I understand that I and anyone for whom I sign as a Parent or Guardian must be of the required age of 7 years or minimum weight of 60 lbs. I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE IT IS MY INTENTION TO EXEMPT AND RELIEVE WILDWATER LTD. FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE. PLEASE SIGN AND FILL OUT COMPLETELY (optional) Age X Signature of Participant Street Address City, State, Zip Print Name IF UNDER 18 FOR PARENTS/GUARDIANS OF PARTICIPANT OF MINOR AGE (UNDER AGE 18 AT TIME OF REGISTRATION) This is to certify that I, as parent/guardian with legal responsibility of this participant, do consent and agree to his/her release as provided above of the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incidents to my minor child s involvement or participation in these programs as provided above. EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. X Parent or Guardian Date Emergency phone number(s) 3/2011

6 2012 Monday, July 30, 2012 Teen Leadership Camp July 30-August 1 Tentative Agenda 10:00 am Arrive at camp and check in 12:00 pm Lunch 1:00-5:00 pm Camp activities (High and low ropes courses, team building, swimming, games) 6:00 pm Travel to Asheville Tourists Baseball Game (4-H Night)- Dinner included 11:00 pm Lights out and in bed Tuesday, July 31, :00 am Breakfast 9:00 am Community service project at campgrounds 10:30 am Leadership workshops 12:00 pm Lunch 1:00-5:00 pm Camp activities (High and low ropes courses, team building, swimming, games) 5:00-6:00 pm Free Time 6:00 pm Dinner 7:00 pm Evening activities (outdoor movie, snacks) 9:30 pm Campfire and s mores 11:00 pm Lights out and in bed Wednesday, August 1, :00 am Breakfast 8:00 am Depart for whitewater rafting at Wildwater Adventures (Nantahala river) 1:30 pm Campers can be picked up by parents at Falling Waters Adventure Resort & Nantahala Gorge Canopy Tours 3:00 pm Depart for home

7 2012 Teen Leadership Camp July 30-August 1 What to Bring Tip Sheet Comfortable Clothes bathing suit (also bring a shirt and shorts for rafting) water shoes (sandals must have heel strap for rafting trip) tennis shoes (or other closed toe shoes) rain gear or umbrella socks pajamas hat Personal Articles wash cloth shower shoes towels for bathing and swimming comb or brush (any other hair accessories) toothbrush, toothpaste soap & shampoo/conditioner deodorant sunscreen sunglasses with a strap Bedding (for bunk-style beds) pillow and pillowcase two (2) sheets & light blanket or sleeping bag Other items (optional) camera water bottle alarm clock reading materials for any down time extra money if you plan to purchase extra food or items at the Asheville Tourists baseball game or Wildwater Adventures Do not bring expensive items to camp such as electronic games, jewelry, radios etc.