4-H TRIBUNE
July 2012
Volume 5 Issue 6
QUALITY ASSURANCE
If you are a new member or have moved to a new age group (Junior to Intermediate,
Intermediate to Senior) you will be required to take the Online Quality Assurance
Program this year. Or, if you are adding a new species to your project list! (Ex. Never
shown goats, adding goats this year.) The program is online and required for ALL 4-H
Members showing beef, dairy, hog, sheep, goats, horses/ponies, poultry, rabbits, and
alpacas/llamas. The website to complete this program is http://www.maryland4h. org/AHQA/
You must register and complete this program if you are going to show. The website is open
and is available 24 hours a day. If you receive an error message while trying to complete it
please let Kathy know.
The CC 4-H Extension Office has a “Computer Lab” which is available to all. Contact Kathy if
you should need to use the computer lab.
Because our fair begins before the state deadline, you will need to complete this
requirement by July 25th!!
Cow Pie Bingo Fundraiser
Don’t miss out on “Cow Pie Bingo” at the Carroll County 4-H & FFA Fair. This bingo
will take place on Saturday, July 28th in Shipley Arena, time to be determined. We
are looking for everyone to spread the word about the county fundraiser. Tickets are
$10 and are available at the Extension office. The winner will receive $250. If you have any
questions contact Becky at 410-386-2760 or bridgewa@umd.edu.
Indoor Building Reminders for the Fair
Make sure you check the online catalog to read the complete description of the classes.
-Cake discs are available in the Extension Office.
-Bring your claim sheet with you on the day of entry. The claim sheet is also needed for entry pick-up
on the release day.
-Photography—Exhibitors are limited to 5 entries total.
-Informal Demo Dept.—Did you pre-register to do an Informal Demo? Don’t forget to call and
schedule a time!
Please come to the Red Building Superintendent table when you arrive if you need to change a class
number. Class changes can only be made within the same department. You will need a new entry tag
from the superintendent table in order to receive your premium for that item.
Any questions, please contact
Sandra Stonesifer, Indoor Superintendent at: 410-857-0416.
Maryland State Fair Entries
Fair Packets will be available on
Saturday, July 21st, at Shipley
immediately after Livestock
Orientation and ending at
3:30pm and on Sunday, July
22nd, at Shipley from 11am to
1pm.
They will then be available in
the CC Extension Office
beginning Monday through
Thursday at noon. After that,
they will be in the Red Building.
FAIR SETUP & CLEANUP
ALL Exhibitors are required to help
with Fair setup and cleanup.
Shipley Building Setup - July 21st at
9am.
Red Building Setup - Sunday July
22nd
Senior and Intermediate exhibitor
set-up will start at 9am and junior
exhibitors will set-up at 11am.
There will be signup sheets, so after
arriving please sign to verify that you
were there to help.
CLERKS FOR INDOOR BUILDING
JUDGING.
Clerks are needed Thurs. July 26 and
Fri. July 27 about 1:30PM, Sat. July
28 about 8:30AM and Wed. Aug. 1
about 8:30AM
Any time would be appreciated.
Thanks, Miss Sandy
Online entry system for the Maryland State
Fair is now open. To register for the state
fair go to www.marylandstatefair.com.
Also, you need to fill out an Exhibitor
Release Form if you are planning on
showing/exhibiting at the State Fair. We
have forms available at the office or they
are online and need to be mailed to the
Maryland 4-H Center.
Don’t forget the online entry system
closes on Tuesday, July 31st at
11:59pm.
Maryland State Fair Youth
Workers
If anyone is interested in working at the
State Fair and learning the ins and outs of
how the Fair works, check out the
Maryland 4-H website for an application.
There are many opportunities to work in
the indoor building and in Animal World for
those with an interest in animals.
MyPlate Poster Contest
at the MD State Fair
Each year there is a healthy lifestyle poster
contest at the Maryland State Fair. All you
have to do is create a poster of this year’s
theme “MyPlate is a Healthy Plate.”
Standard poster board must be used, but
it’s up to your imagination to create the
poster! The best part is that you don’t
have to enter the poster, contact Becky
Ridgeway
at
410-386-2760
or
bridgewa@umd.edu if you’re interested
and we will get you registered and take
your poster to the state fair! Complete list
of
guidelines
can
be
found
at
www.marylandstatefair.com.
Demonstration/Public Speaking/
FashionRevue at the MD State Fair
If you participated in the county demonstration/
public speaking days, consider taking your
presentation to the state fair! Find the
registration form at the end of the Tribune.
Section Rules & Regulations:
1. Registration: To register for this event, fill
out the page attached to this Tribune and
send in to the Maryland 4-H Center by July
31st.
2. Presentations must have been presented
at least one time at the county/city level
and may be one of the following:
a. Demonstration (if kitchen use is required,
please note it on the form. No food may be
offered to judges or the general public.)
b. Visual Presentation
c. Prepared Speech
d. Radio Public Service Announcement
e. Interpretations
(Dramatic,
Humorous,
Poetry)
f. Talent/Share the Fun
g. Mini Fashion Revue – feel free to sign up for
a time as a county group
h. Mannequin Modeling - feel free to sign up
for a time as a county group
3. Presentation Length: Presentations will be
given once and must be 3-15 minutes in
length (Exception: Radio PSA and Talent
Presentations may be less than 3 minutes
and may be asked to repeat their
presentation.)
4. Presentation Schedule: Indicate on the
registration form the preferred day(s) and
time frame. Presentations will be scheduled
as they are received. The schedule will be
mailed to the 4-H participants before the
start of the Maryland State Fair.
5. Equipment: Microphones and easels will be
provided. Participants must provide all other
supplies and equipment needed for the
presentation.
6. Awards: Participants will receive a ribbon
and a premium. Blue - $15, Red - $13 and
White $10 – this reflects an increase in
2011.
Dairy Judging Practice schedule:
More practice dates to come!
If you have any questions please contact
Kelly Zepp at 410-635-3922.
UME Volunteer Leader Training
Would you like to be a University of
Maryland Extension Volunteer? Are you
helping out at club meetings with projects
or activities? Do you have parents in your
club who have expressed an interest in
being a 4-H volunteer?
Please call the Extension Office at 410386-2760 to register.
Poultry Judging
If you are interested in Poultry, take
advantage of poultry judging. All practices
are held at the CC Extension Office in
Room C. Any 4-Her, Clover or FFA
member is welcome, along with parents
too. Call Kelly Hale (410-596-1332) or
Glenn Haines (410-756-2113).
The dates of practices are:
Tues 7/3
Tues 7/10
Tues 7/17
Livestock Judging!!
Yes, it’s time to begin Livestock Judging
once more!! Yeah!! Hope to see you there!
July 10 - Rill’s Sheep, 6:30pm
July 12 – Baltimore County Fair, 9am
These are practices scheduled
so far. We will let you know
when more are scheduled.
For Questions, call Kathy, 410386-2760.
Consumer Education Judging
Reminder: There is one more consumer
education practice before the county
contest:
July 9th - Light Bulbs & Grain I.D.
County Consumer Education Judging
Contest: Monday, July 23rd from 7-9 pm
Attention High School Senior 4-H
Members!!
In the CC Extension Office is a book of
Scholarship applications. They are also
on our website. There are various due
dates for these applications, from mid-April
to July. Please come in and look them
over, there may be something that you can
apply for…don’t lose the chance to get
money for your education!!
2012 Horticulture Judging
Do you think you know your plants,
vegetables, flowers, and bugs? If you think
you do, then participate in the Carroll
County Fair Horticulture Judging Contest! If
you have any questions or are interested,
please email Tommy Diffendal at
for
more
farmertommy@hotmail.com
information! Practice will be on July 18th at
7pm at the Extension Office.
4-H CLUB LEADERS!!
The Public Relations Efforts (AA-4-H4)
form should have been submitted to the
4-H Office by February 1. We are still
waiting for this form from the following
clubs:
CC Teen Council
Gunpowder
Wakefield Valley
Westminster
If you need another copy of this form, we
have extras in the office.
We are still waiting for The Annual
Financial Summary Report from the
following clubs:
CC Teen Council
Flaming Arrows
Horse of Course
SC Tree of Life
Send all of the above to Debbie’s attention
ASAP.
We would like to congratulate Brittany
Lippy and Brandon Kahler for being
selected to represent Maryland at the
National 4-H Congress later this year.
Outdoor Recreation Club!!
Do you have an interest in exploring the
outdoors? Would you like to learn basic
outdoor survival skills? Do you like to hike
and camp?
If you answered “yes,” “maybe,” or “I don’t
know” to any of these questions, then there
may be a new opportunity for you in 4-H! If
you are interested in being a part of this
club as a member or a volunteer please
contact Jim Serfass at 410-386-2760 or
jserfass@umd.edu.
Science Exploration Days
Come out to the Carroll County Extension
office and spend the day exploring a
variety of science-based activities. We’ll
spend the day learning how to use GPS
and iPad’s and will construct a roller
coaster! We will also do experiments to
learn about the environment, animals and
our food.
Don’t miss out on these two fun filled days!
Sign up for just one day or come both,
Thursday, August 16th and Friday, August
17th from 9am to 3pm, limited space is
available. If you are interested, please call
the Carroll County Extension office to sign
up. If you have any questions, please
contact Becky Ridgeway at 410-386-2760
or bridgewa@umd.edu
Miss Carroll County Farm Bureau
Are you a young lady between the ages of
16 – 19 who has an interest in and
appreciation for agriculture? If so, the Miss
Carroll County Farm Bureau Contest may
be the perfect opportunity for you. Formerly
known as the Carroll County Farm Queen
contest, the Miss Carroll County Farm
Bureau contest provides young women
with the opportunity to share their
knowledge of agriculture and Farm Bureau
with people around the county and state.
For more information, please contact Angie
Bachtel at angelarasche@gmail.com or
443-277-6518. Application deadline is July
15, 2012.
As part of their community service project,
the following Pleasant Valley 4-H Club
members participated in the Pleasant
Valley Community Memorial Day Parade
and Ceremony on May 27, 2012: Kaitlyn,
Jordan, and Taylor Blizzard, Katie
Fairbank, Jenn Norris and Suzy Spriggs.
Members helped place about 100 flags on
veterans’ graves. Kaitlyn, Jordan, and
Taylor Blizzard, Katie Fairbank, Makenzie
Gawel, Dylan Groft, Abby Love, Alexis
Love, Jenn Norris, and Suzy Spriggs
assembled pins to present to veterans,
long-time residents and other attendees at
the service. Kaitlyn Blizzard led the Pledge
of Allegiance to the Flag. Members learned
about the importance of honoring veterans,
and also about Pleasant Valley area
history.
ARE YOU INTERESTED IN GRAPHIC
ARTS, PHOTOGRAPHY,
VIDEOGRAPHY, MARKETING OR
WEBSITE DESIGN?
The Super Sonic Sparks 4-H Robotics
Team is planning to add a marketing group
to their team. The Team competes in 5 to
10 local (MD, PA and VA) VEX Robotics
events per year and has attended the VEX
Robotics World Championship for the past
4 years.
The VEX Robotics Program includes
aspects that involve use of graphic arts,
videography,
photography,
website
development, computer animation and
creative writing, and we would like to
improve our performance in these areas by
adding a group of up to three 4-H members
with those interests and skills.
The marketing team would work very
closely with the rest of the team in order to
understand the technical work being done,
and would translate that understanding into
marketing materials to be used for
promoting the team, seeking sponsorships,
supporting the judge interviews at
competitions, and various written and
creative
submissions
for
World
Championship.
Members of the marketing group would
need to attend most team meetings
(Monday nights, weekly) and would travel
and participate as integral members of the
overall team. We are working to form a
partnership with a local marketing and
graphic arts company to serve as mentors.
If you are going to be in 7th to 12th grade
this next school year and are interested,
please
contact
David
Franc
at
davidfranc12@yahoo.com or 410-2592749.
Horse Exhibitors!!
For the County Fair the following is required:
Exhibitors - English and Western, must have passed Horsemanship Standards Levels 1 &
2 for Knowledge and Levels 1, 2, & 3 for Riding to show at a canter or lope at the 2012 County
Fair. A copy of the tests must be presented to the 4-H Office by the tester to be placed on file.
Riders only passing Standards Levels 1 & 2 for Riding will be restricted to entering the Short
Stirrup Walk, Walk/Trot classes, Long Stirrup Walk, Walk/Trot classes, and Western walk/jog
classes. If you previously rode at a canter or lope at the fair, you cannot step down to the
walk/trot or walk/jog classes with the mount you rode at a canter or lope.
Starting at the 2013 Fair, riders will have to pass Jumping Levels 1 & 2 to show in the
Short Stirrup and Long Stirrup jumping classes and for the Pleasure and Hunter classes, riders
will also have to pass Jumping Level 3. This will finally bring us in line with State Fair 4-H Horse
Show requirements. You now have more than a year to pass the jumping levels, so please don't
wait until the last minute.
For State Fair the following is required per the Horse and Pony Rule Book:
A 4-Her must have successfully passed Maryland 4-H Horsemanship Knowledge and Riding
Levels 1 & 2 and English or Western Riding Level 3. 4-Hers entering a jumping class must
specifically pass English Riding Jumping Level 3. 4-Hers showing in halter or showmanship
classes ONLY are required to have Knowledge Levels 1 & 2 and must have prior approval by
their club leader and/or County Extension Educator. All rankings must be on file at the county 4-H
office prior to the State Fair.
If you have any questions about the above, call Kathy D.
Kathy Gordon
Extension Educator
4-H Youth Development
kgordon1@umd.edu
Jim Serfass
Extension Educator
4-H Youth Development
jserfass@umd.edu
Becky Ridgeway
Extension Educator
4-H Youth Development
bridgewa@umd.edu
www.carroll.umd.edu/4h The Carroll County 4-H Website. Find The Tribune online, plus other forms and
information for youth and leaders.
www.maryland4h.org The Maryland State 4-H Youth Development Website. News & information from all over
the state, plus forms and information for youth and leaders.
Carroll County 4-H Youth Development
University of Maryland Extension
700 Agriculture Center
Westminster, MD 21157-5700
Phone:
Toll-Free:
Fax:
410-386-2760
888-326-9645
410-876-0132
It is the policy of the University of Maryland Extension that no person shall be subjected to discrimination on the grounds of race, color,
gender, religion, national origin, sexual orientation, age, marital or parental status, or disability.
If you have a disability that requires special assistance for your participation in a program, please contact the Carroll County Extension
Office at 410-386-2760, fax: 410-876-0132, two (2) weeks prior to the program.
The information given herein is supplied with the understanding that no discrimination is intended and no endorsement by University of
Maryland Extension is implied.
2012 Exhibitor Requirements for Animal Health
Livestock Exhibitors: (Dairy, Beef, Sheep, Swine, Goats, Alpacas)
CVI and Self Certification form
Equine Exhibitors:
Valid Coggins test within the last 12 months
Equine Self Certification Form
Poultry Exhibitors:
Proof of MD Poultry Premise ID number
Avian Influenza Test
Pullorum-Typhoid Test
Poultry Self Certification Form
Rabbit & Cavies Exhibitors:
Self Certification Form
*** A person may not show livestock at any petting zoo, unless all exhibited animals in the petting zoo,
105 days of age or older, are vaccinated against rabies as provided in COMAR 10.06.02, unless there
is no rabies vaccine licensed and approved by the USDA for that animal species. Approved species
are Cattle, Sheep, Horses, Dogs, Cats, and Ferrets.
Upcoming Dates to Remember…
July 6
July 9-12
July 14
July 13-15
July 16-20
July 23
July 28-Aug 3
July 31
Aug 16-17
Aug 22–Sept 3
Goat Workshop at Novotny Farm, 7 pm
CC 4-H Clover Camp, CC Ext Office, 8:30 am – 4 pm
Fair Day at the Mall
State 4-H Horse Jamboree, Hashawha
CC 4-H Camp, Hashawha
CC Consumer Education Judging Contest, CC Ext Office, 7pm
Carroll County 4-H/FFA Fair
Maryland State Fair Online Entries Closes at 11:59pm
Science Exploration Days, CC Ext Office, 9am – 3pm
Maryland State Fair
Cover Contest – Deadline Extended! Attached to this Tribune are the rules and regulations
for the cover contest for the 2012 Carroll County 4-H/FFA Fair. The theme for this year is:
OUR KIDS, OUR FAIR, OUR FUTURE. Get those entries in, due date is July 25!
7
2012 Maryland State Fair 4-H Entry Form
Division X – Special 4-H Programs
Entry Deadline: This entry must be received at
the Maryland 4-H Center on or before
July 31, 2012. No late entries will be accepted.
Maryland 4-H Center
Linda Walsh
8020 Greenmead Drive
College Park, MD 20740
County/City: _____________________________ County/City Code: _____________________________
SECTION VI – 4-H PRESENTS! PROGRAM
Exhibitor Name: ___________________________ Birthdate: ___________________________________
Address: __________________________________ Phone Number: ______________________________
Team Members (If Applicable): ____________________________________________________________
Type of Entry (Check One):
� A. Demonstration - Is Kitchen needed? Yes ___ No ___
� B. Visual Presentation
� C. Prepared Speech
� D. Radio Public Service Announcement
� E. Interpretations (Dramatic, Humorous, Poetry)
� F. Talent/Share the Fun
� G. Mini Fashion Revue (feel free to sign up for a time as a county group)
� H. Mannequin Modeling (feel free to sign up for a time as a county group)
.
Preferred Date (Please Check Top 3 Choices):
� Friday, August 24th 5:00 – 8:00 pm
� Sunday, August 26th 10:00 – 1:00 pm
� Monday, August 27th 5:00 – 8:00 pm
� Tuesday, August 28th 5:00 – 8:00 pm
� Wednesday, August 29th 5:00 – 8:00 pm
� Thursday, August 30th 5:00 – 8:00 pm
� Friday, August 31st 3:00 – 6:00 pm
� Saturday, September 1st 1:30 – 3:30 pm
� Sunday, September 2nd 11:00 – 2:00 pm
8
Congratulations to all the participants in this year’s
Fashion Revue!
Thank you to all of the committee members and youth members for all of
their continued hard work to make the Fashion Revue a great day for all of
the participants and their families!
Clovers
Lilly Bruns
Carly Chaney
Colleen Haines
Jacquelyn Harmon
Mckenna Lanza
Ryleigh Lanza
Layla Metts
Makenna Steele
Juniors
Marissa Roberts – Champion Constructed Dress, Reserve Grand Champion Constructed
Allison Stoner – Champion Constructed Sportswear, Grand Champion Constructed
Hannah Haines – Champion Ready-To-Wear (RTW) Sportswear
Payton Steele – Reserve Champion RTW Dress
Courtney Patterson – Champion RTW Dress, Grand Champion RTW
Jarrett Wagner – Champion RTW Separates, Reserve Grand Champion RTW
Intermediates
Madison Collins – Champion Constructed Creative Choice, Res. Gr. Champion Constructed
Abigail Stevens – Champion Constructed Separates
Hailey Kasten – Champion Constructed Dress, Grand Champion Constructed
Hailey Kasten – Champion RTW Dress, Reserve Grand Champion RTW
Allison Parrish – Reserve Champion RTW Costume
Emily Kemp – Champion RTW Costume
Jordan Wagner – Champion RTW Separates, Grand Champion RTW
Seniors
Brittany Lippy – Champion Constructed Business Professional, Grand Champion Constructed
Brittany Hill – Champion Ready-To-Wear Formal, Grand Champion Ready-To-Wear
Top 13 Year Old – Hailey Kasten
Best Accessorized – Brittany Lippy
Best Model - Jordan Wagner
9
Your Milk Comes from a Good Place!
Dairy
•
•
•
•
•
E
ach and every day, America’s dairy farmers
invest their time, energy and passion into
producing wholesome milk for you and your
family. Dairy farmers take good care of their
animals and the land that they farm. They
are active members of the community and
contribute to the local economy. They are your
friends and neighbors. Most important of all,
they are dedicated to producing nutritious
and great tasting milk and dairy foods for all to
enjoy.
Learn more about dairy farming and why
“Your Milk Comes from a Good Place” at
www.dairyspot.com.
•
•
•
Facts About Maryland
There are 495 dairy
farms in Maryland.
The most popular
dairy breed in our
state is the Holstein.
Milk is Maryland’s
official State
Beverage.
Maryland’s dairy industry accounts for
$182.7 million in sales in 2010.
Frederick,
Washington and
Carroll counties
are Maryland’s top
3 dairy counties.
Maryland dairy
cattle are routinely
judged among the
best in the world at competitions.
Carroll County dairy farmer Donna
Myers was chosen Dairy Woman of
the Year at the 2011 World Dairy Expo
in Madison, Wisconsin.
There are about 55,000 cows in
Maryland.
Ice Cream Trail
Be a
Trail Blazer!
Maryland has
seven dairy farms
that offer fresh,
delicious onfarm ice cream.
Together, they
make up the
newly minted
Maryland Ice
Cream Trail. Visit
each creamery
between June 20
and September 7,
and you may be
named. . .
Maryland’s 2012
Ice Cream Trail Blazer!
Governor Martin O’Malley
Lt. Governor Anthony Brown
Secretary Earl F. Hance
Deputy Secretary Mary Ellen Setting
This is your
Geocache Trail Passport
Maryland’s Best Ice Cream Trail
Maryland’s Ice Cream GeoCache Passport
Stamp passport
here!
2.
6.
Baltimore County
5.
3.
Bobby’s Black Mud - GC3NT5Y
1. Prigel Family Creamery
www.prigelfamilycreamery.com
1.
4.
Cecil County
Cowconut - GC3NT50
2. Kilby Cream
www.kilbycream.com Frederick County
Monkey Butter -GC3NT6P
3. South Mountain Creamery
www.southmountaincreamery.com
How You Can Be
a Geocache Trail
Blazer!
As you travel around the state this summer
geocaching, visit each of these caches and
stamp them with the stamp in the cache.
Visit each geocache by Sept. 7, 2012,
and mail your completed Trail Passport
to: Maryland’s Best Ice Cream, Maryland
Department of Agriculture, 50 Harry S.
Truman Parkway, Annapolis, MD 21401. All completed passports will be rewarded
with a collectable Maryland’s Best Ice
Cream Trail Pathtag.
Grape Nut
GC3NT7H
4. Rocky Point Creamery
Harford County
Black Raspberry - GC3NT5M
7.
We will also have a drawing to pick winners
of a DVD of The Maryland Harvest, an
hour-long documentary about renown
Maryland chefs and their partnerships with
local farmers, and a copy of the acclaimed
cookbook Dishing Up Maryland by Lucie
Snodgrass. And incredible bragging rights!
Be sure to include your mailing address and phone number when you mail in your
Passport! Enjoy the trail!
The Geocaching.com logo is property of Groundspeak, used with permission
5. Broom’s Bloom Dairy
www.bbdairy.com
Washington County
Dizzy Cow - GC3NT69
6. Misty Meadows Farm Creamery
www.mistymeadowfarmcreamery.com
Worcester County
Farmer Dan’s Caramel Fudge
GC3NT1Q
7. Chesapeake Bay Farms, Inc.
www.chesapeakebaycheese.com
COVER CONTEST
Cover Contest Chair – Lynn Talbert (410-635-6648)
DIVISION A – Program Covers Contest – Rules and Regulations
1. Entry must be drawn to exact size of 8” x 10 ½”.
2. Entries are due to the Carroll County Extension Office (4-H), 700 Agriculture Center,
Westminster, MD 21157, Friday June 1, 2012
3. Design should be simple, not involved, nor complicated.
4. Design should be original. Do not use registered trademarks in your design. Care must be
taken to use the 4-H emblem in an acceptable manner.
5. Design must include the following information: “Carroll County 4-H FFA Fair our Kids, our Fair, our
Future”
6. Only Carroll County 4-H or FFA members in good standing may submit entries.
7. Name, age (as of 1/1/12), address, club name, and class number must be printed on the
back of the entry.
8. Carroll County 4-H & FFA Fair Board reserve the right to alter the design.
9. Copies of the entries will be used for covers of various show programs available throughout
the Fair.
10. All entries will be exhibited at the Carroll Co. 4-H & FFA Fair. Exhibits will be released with other
indoor exhibits.
11. Entries will be judged on the Danish System. Premiums – Champion - $10; Reserve
Champion - $8; Blue Award - $5; Red Award - $3; White Award – $1.50. Clover participants
- $1
Classes - Division A - Cover Contest
00001 Clover Entry (ages 5-7)
00002 4-H Entry (ages 8-13)
00003 4-H or FFA Entry (ages 14-18)
00004 Champion Cover Contest Entry
00005 Reserve Champion Cover Contest Entry
UNIVERSITY OF MARYLAND
UNIVERSITY OF MARYLAND EXTENSION
PARENTAL RELEASE AND INFORMED CONSENT FORM
PROGRAM: Carroll County 4-H Science Exploration Days
DATE(S): August 16-17, 2012
[To Be Completed in Ink] [Signatures Required on Both Sides of Form]
My minor child, as listed below, has my permission to fully participate as a representative of the University of Maryland Extension (UME) Maryland
4-H Youth Development Program in all activities associated with the above named program.
In connection with and consideration of my child’s participation in the Program, I, on behalf of my child and myself, my heirs, personal
representative(s) and assigns, hereby represent and agree as follows:
1.
I am aware that any program related activity can be dangerous, and I fully recognize and understand that there are risks
and hazards, both minor and serious, associated with participation in the Program and related activities, including, but
not limited to: cuts, scrapes, bruises, broken bones, muscle strains, pulls or tears, head, neck, back, eye and other bodily
injuries, heat prostration, brain damage, blindness, deafness, drowning, heart attacks, paralysis and, even, death. The
following is a description and examples of specific, significant, non-obvious dangers and risks associated with this
activity. There is potential for accidents and/or injuries arising from:
a. Participating in activities outdoors which may involve moving along uneven ground
b. Taking part in activities involving craft materials such as glue, scissors, etc.
c. Weather related events
2.
I understand that my child is not in any way required to participate in the Program, but I want them to participate, despite
the possible dangers and despite this Release.
3.
I represent and warrant that my child has no physical, health related or other problems which would preclude or restrict
their participation in the Program or otherwise render their participation dangerous or harmful to them or others. I
further represent and warrant that my child has adequate medical, health and/or other insurance for participation.
4.
Knowing the dangers, hazards and risks associated with the Program, and with sufficient knowledge of my child’s
physical condition(s) and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage, illness
and/or injury to person or property which my child may, in any way, sustain in connection with participation in the
Program and related activities.
5.
I agree that my child must abide by all rules and regulations applicable to participation in the Program. Should my child
require emergency medical treatment or first aid as a result illness or injury associated with the Program or related
activities, I consent to such first aid and/or treatment.
6.
To the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and to indemnify and
hold harmless, the State of Maryland, the University of Maryland, University of Maryland Extension and their governing
boards, officers, agents, employees and volunteers from and against any and all liabilities, claims, demands and causes of
action of any kind on account of any loss, damage, illness or injury to person or property in any way arising out of or
relating to my child’s participation in the Program and/or related activities, whether due to the negligence, mistake or
other action or inaction of UME or any other person or entity.
7.
I do hereby consent and agree that the Maryland 4-H Youth Development Program has the right to take photographs or record video/audio tapes
of my child and to use these for educational and/or promotional materials. I further consent that my child's name may be revealed therein or by
descriptive text or community. I hereby release to the Maryland 4-H Youth Development Program all rights to exhibit this work publicly or
privately, including posting it on the Maryland 4-H Website. I waive any rights, claims or interests I or my child may have to control the use of
my child's identity or likeness in the photographs, video or audio, and agree that any uses described herein may be made without compensation
or additional consideration of me or my child.
I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ AND FULLY UNDERSTAND THIS RELEASE AND
INFORMED CONSENT FORM, AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.
Signature of Parent/Guardian Having Care and Custody of Participating Child
Emergency Telephone: (
Name of Parent/Guardian:
Participating Child’s Name:
Date
Signature:
)
Age:
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age, sexual orientation, marital or parental status, or national
origin.
Rev. - July 2000 (D. Andrews)
Updated for Extension Name and Logo Change
AMT 3/2010
Participant’s Name (Print) __________________________________________________________________
UNIVERSITY OF MARYLAND
UNIVERSITY OF MARYLAND EXTENSION
PARENTAL RELEASE AND INFORMED CONSENT FORM
Person’(s) other than custodial parent/guardian authorized to take my minor child from site:
** Take emergency contacts from Health Statement ____ Yes
____ No **
Name __________________________________
Relationship ____________________ Day Phone _________________
Name __________________________________
Relationship ____________________ Day Phone _________________
Program Release
The program may include the following activities. Safety equipment, supervision, training, and staff will be provided for
these and for all other activities. No one is compelled to participate but all are encouraged to attempt all activities. Advise your child
if he/she is NOT to participate per your directions. Your initials will indicate that your child has permission to
participate.
_____ Insect/Invertebrate Collection – As part of several hands-on lessons, participants may be collecting aquatic and
terrestrial insects and other “bugs” using nets and other equipment. In some cases, participants may touch the insects directly.
_____ Hiking – Participants will take short hikes around Landon C. Burns Park and the area surrounding the Agricultural
Center.
Program Policies and Provisions
I have read and reviewed the following documents and understand the contents and intent of each. I further understand that
disciplinary action, up to and including permanent removal from program, may be the outcome of failure to comply with the stated
rules and expectations. Initial below to indicate you and your child have read and agree to comply with the stated
rules, policies, and provisions:
____ Participant/Parent Letter
____ 4-H Participant Behavioral Expectations
Permission to Transport
Permission is hereby given for _____________________________ to be transported during the course of the 4-H program as
need is determined by the program staff, in a provided vehicle, within the boundaries of the facility or outside for emergency medical
treatment. Said vehicle to be operated by an adult staff member and provided by the program. (In the event of medical emergency,
Carroll County Volunteer Emergency Services will be called for transport via ambulance.)
I understand the nature of this program, that transport, boarding, embarking and disembarking involve a calculated risk, that
all possible precautions and care will be taken.
I intend to be legally bound, do waive and release and hold harmless all claims for damages against the vehicle owner, the
vehicle operator, University of Maryland Extension, Carroll County Extension, , Carroll County Commissioners, employees, EAC
officers, agents and/or volunteers and assigns thereof from any and all claims, actions, liabilities which I, for myself or on behalf of
another, may have from personal injuries, illnesses, or losses which occur while ________________________________ is attending
Carroll County 4-H Science Exploration Days. I have read all policies and regulations as provided and understand the terms. I
execute this voluntarily and with full knowledge of its significance.
Parent/Guardian Name (Printed):_______________________________________
Signature of Parent/Guardian or Adult Attendee____________________________________Date______________________
If I am instructed to ride in a vehicle, I agree to follow all directions as given to me by staff.
Participant
Signature______________________________________________________________Date________________
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability,
religion, age, sexual orientation, marital or parental status, or national origin.
2 fun filled days of learning about the environment, technology,
foods and animals!!
-
Let your imagination run wild as you work with your team
and build a roller coaster from recycled materials.
-
Get outside! We will learn about GPS and compasses while
finding our way around outside!
-
Learn about where your food comes from and what’s in
it. Maybe even make a special treat!
AND MANY MORE ACTIVITIES!!!
Thursday, August 16th and Friday, August 17th from 9am – 3pm
at the Carroll County Extension Office
Participation is limited; get your forms in fast before the days are filled.
If you have questions, please feel free to contact Becky Ridgeway at 410-386-2760 or bridgewa@umd.edu
Carroll County 4-H Science Exploration Days
Name: _____________________________________
Age as of Jan. 1: __________________
Address: ______________________________________________________________________
Phone #:____________________________
Email: __________________________________
Days of Participation (Please circle one):
Both Days
Thursday Only
Friday Only
Forms are due by Friday, August 3rd to:
Carroll County Extension Office
Attn: Science Exploration Days
700 Agriculture Center
Westminster, MD 21157
Make sure to include Emergency Notification Information and Parental Release Form
University of Maryland Extension programs are open to all citizens without regard to race, color, gender, disability, religion, age,
sexual orientation, marital or parental status, or national origin
EMERGENCY NOTIFICATION INFORMATION
NAME: ____________________________________________________ DOB: _________________
ADDRESS: _________________________________________________________________________
IN CASE OF EMERGENCY, NOTIFY:
NAME: ______________________________________ PHONE: __________________________
RELATIONSHIP: ________________________________ CELL PHONE: ______________________
ALTERNATE CONTACT –
NAME: _______________________________________ PHONE: __________________________
RELATIONSHIP: ________________________________ CELL PHONE: ______________________
ALLERGIES:
TO:________MEDICATION _______ PENICILLIN _________ ASPIRIN
________OTHER (specify): ________________________________
_______________________________________________________
CURRENT MEDICATIONS: ___________________________________
Any medical conditions or other information we should be aware of:
_________________________________________________________
AUTHORIZATION FOR PARTICIPATION AND RELEASE: I hereby give permission
for medical personnel selected by University of Maryland (UME) to provide routine
health care; to order x-rays, and routine tests; to administer medications, injections, and
to provide or arrange necessary related transportation for me/my child. In the event I
cannot be reached in an emergency, I hereby give permission for medical personnel
selected by UME to secure and administer treatment including hospitalization for the
participant named above. I further understand that I will be responsible for
medical/hospital bills. By signing this form, I give permission for the participant named
herein to participate in all program activities except as specified herein. This completed
form may be copied for trips out of the facility and/or away and to indemnify and hold
harmless the State of Maryland, University of Maryland, University of Maryland
Extension and/or their officers, agents, employees, faculty, staff, and volunteers from
and against any and all liabilities, costs, expenses, causes of action, claims, and/or
demands in any way relating to the foregoing program activities and/or the health,
illness, injury, and/or treatment of the participant named above.
I AM 18 YEARS OLD OR OLDER AND I HAVE READ AND FULLY UNDERSTAND
THIS AUTHORIZATION FOR PARTICIPATION AND TREATMENT AND RELEASE.
______________________________
______________________________
Signature of Participant or Parent/Guardian
If participant is under 18 years old
Print Name of Participant or Parent/Guardian if
participant is under 18 years old
_______________________________________
Signature of Parent/Guardian of 18 yr. old
(Optional)
(OR)
________________________________________
Print Name of Parent/Guardian of 18 Yr. Old
(Optional)