June 8-9, 2013
When: Saturday, June 8 (stay over Saturday night). Clinic ends at 12:00 pm Sunday, June 9.
Where: DuPage County Fairgrounds, 2015 W. Manchester Road, Wheaton, IL 60187
Check in time is 7:00--8:00 a.m. on Saturday. The Saturday activities will begin at 8:30 a.m. with a
mandatory parent and participant meeting followed by start of the clinic.
Saturday Clinic – DuPage County 4-H alum Kayla Wells and Sarah Schobert will team up to be the
clinicians this year.
The clinic format will be similar to last year with a mock show. Both English and Western classes
will be offered. Participants will be placed in the appropriate level based on performance and
given feedback and suggestions for improvement. Participants will then be broken into smaller
groups to have the opportunity to work on the areas where they need practice. Throughout the
day there will be a variety of learning opportunities (still to be confirmed).
Cost: $50.00 for each participant. The price includes the clinic, lunch and dinner on Saturday and
breakfast on Sunday, and horse stall rental. 4-H’ers without a horse may participate as an observer
for a fee of $15.00 which will cover meals. Meal tickets for non-participants are available for
$3.50 per meal. Order your extra meal tickets at time of sign up/registration. Items to bring are
included in this packet.
Sign Up Deadline: 4:00 pm Friday, April 26th. Send registration form, health form, and fees for
the clinic and additional meal tickets to (please make checks payable to JUST SAY NAY):
Cassi Williston
DuPage County Overnight Clinic Horse Committee
0N726 Morse St.
Wheaton, IL 60187
IMPORTANT MANDATORY PARENT MEETING : MAY 16 at the DuPage County
Fairgrounds (4-H Building) after Just Say Nay club meeting
(approximately 8:00 p.m.)
University of Illinois at Urbana-Champaign College of Agricultural, Consumer and Environmental Sciences
United States Department of Agriculture - Local Extension Councils Cooperating
University of Illinois Extension provides equal opportunities in programs and employment.
Volunteer Roles
Volunteers are necessary to run this event. Every family must volunteer in some capacity. Below are specific
needs. Please indicate your top three preferences on the registration form included in this packet. Every
effort will be made to place you in the area of preference, but it cannot be guaranteed. You may be asked
to help in another area.
All parents/chaperones are expected to ensure that horses are under control at all times and everyone is following
safety procedures and the 4-H Code of Conduct.
1.
Food committee (June 8 & 9) – The food committee is responsible for helping to plan, set up and clean up at meal
and snack times. If we get several people to sign up then we may not need everyone at every meal. Please jump in!
2.
Check-in workers for the clinic (June 8) – We need people to help at the check-in table to give instructions and
information.
3. Check-out persons (June 9) – This person will check the stalls to ensure that all shavings and manure have been
shoveled right in front of the stall (not in the ditch).
4.
Clinician representative (June 8) – This person will ensure that our clinician has water, sunscreen, umbrella,
breaks, etc.
5.
Trail/dressage & jumps and gaming equipment (June 8) – We need crews to set up and remove trail obstacles,
dressage arena and jumps.
6.
Donations (June 8 & 9) - Help get food donations from local merchants prior to Clinic and pick up for Clinic days.
7.
Help with games (June 8 & 9) – Help plan, organize, and run the horse games.
8.
Photographer – take pictures of the participants throughout the day. Be willing to share the photos and put them
on the JUST SAY NAY Facebook page.
9.
Supervise and enlist participant help in policing the grounds for litter, manure and etc.
Anyone who has a trailer for hire (June 8 & 9) - Some of our exhibitors have horses but no way of getting them to the
fairgrounds. Please let Christine Birns, at the Extension office, know if you would be willing to trailer another exhibitor’s
horse and we will put your name on a list for people to call. You can work out the details as far as costs. We will try to
match up areas where people are coming from. (Is this a volunteer job?
In addition, we would like to borrow large crock pots (or better yet a large electric roaster), and coolers with ice to
offer relief from the sun on (June 8 & 9). A canopy is also needed.
2013 4-H Horse Clinic
“Things to Bring” Checklist
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1. Coggins Papers!!!! No Exceptions. Horse will not be allowed to stay on the grounds
without current Negative Coggins papers.
2. Bedding for yourself & for your horse.
3. Food for your horse (hay and grain)
4. Dish to pass for Saturday lunch and dinner. A-L Dessert, M-Z side or salad. If your
dish requires refrigeration, we will have a few coolers; however, we would appreciate anyone
who is bringing a refrigerated dish to handle the responsibility for keeping it cool. The food
committee will decide what dishes will be put out during the two meals.
5. Snack to share during the weekend
6. Pitchfork and shovel (snow shovel works great) for cleaning your stall as well as a muck
bucket or wheelbarrow.
7. Water bucket
8. Rope to tie your stall shut
9.Extra lead rope and halter
10.Grooming tools
11.Clothes for mock horse show. Proper show attire is not necessary but pants, shirt with
sleeves along with appropriate footwear are required. (NO tennis shoes are allowed
while riding at any time during the weekend)
12.Extra clothes. If it rains, you’ll get soaked.
13.Flashlight
14.ATSM approved riding helmet (You must wear your helmet anytime you ride.
Helmet is required for all classes regardless of discipline.)
15.Toiletries and towels. Showers will be available in the bathrooms.
16.Your own water bottle
17.Insect repellent – for you and your horse.
18. Breast collar - if doing gymkhana games (gaming).
In addition – you may wish to bring a small cooler with refreshments as the only food available on the grounds
will be served at meal times.
Also, most people sleep in empty stalls, but tents and campers are welcome. Electric and water hook ups are
available for campers at a cost of $10.00/day/hookup. Enclose your payment with the registration.
University of Illinois Extension
CODE OF CONDUCT FOR 4-H EVENTS & ACTIVITIES
ALL participants (youth and adults) in events and/or activities planned, conducted, and supervised by the University of
Illinois Extension and 4-H, are responsible for their conduct to U of I Extension personnel and/or volunteers supervising
the events. This responsibility is necessary for the health, safety, and welfare of the participants, and will be rigidly
adhered to and uniformly enforced.
The following conduct is not allowed while participating in any 4-H event or activity and is subject to disciplinary action:
Category 1
a) Possession, use, or distribution of alcohol and other drugs, including tobacco products.*
b) Theft or destruction of public or private property
c) Involvement in sexual misconduct or harassment
d) Possession or use of dangerous weapons or materials (including fireworks)
e) Fighting or other acts of violence that endanger the safety of the participant or others
Category 2
a) Willfully breaking curfew
b) Unauthorized use of vehicles
c) Leaving the site of the event
d) Participation in gambling
e) Absence from the planned program
f) Intentionally interfering with or disrupting the event
g) Use of profane or abusive language
h) Disregard for public or personal property
i) Public displays of affection or inappropriate actions
j) Failure to comply with direction of Extension personnel, including designated adults acting within their duties
and guidelines
* Prescription drugs must be listed on “Emergency Medical Information”
Consequences:
For anyone found in violation of this Code of Conduct (category 1 or 2), University of Illinois Extension reserves the right
to restrict participation in future activities.
In all cases, the participant will be responsible for restitution of any damages incurred by his/her actions.
Deadline: Friday, April 26 by 4:00 pm
DuPage County 4-H
Overnight Horse Clinic Registration Form
Mail registration form, participant’s health form and payment to (checks made out to JUST SAY NAY):
Cassi Williston
DuPage County Overnight Clinic Horse Committee
0N726 Morse St
Wheaton, IL 60187
Participant Name: ___________________________________________ Age: ____________________
Ability Level:
Beginner
Intermediate
Advanced
E-Mail address: ________________________________________________________________________
Home Phone: ______________________________ Alternate Phone: ___________________________
Parent/Guardian Name(s):_______________________________________________________________
4-H Club Name: _______________________________________________________________________
Name of adult chaperone(s) attending clinic with 4-H’er:________________________________________
Note:
1.
2.
All 4-H’ers must have a designated adult chaperone on premises at all times, including overnight.
All parents and/or chaperones must complete an on-line orientation at
http://web.extension.uiuc.edu/4hchaperone/
Equine Statement and Parental Consent:
Warning
Under the Equine Activity Liability Act, each participant who engages in an equine activity
expressly assumes the risks of engaging in and legal responsibility for injury, loss, damage to
person or property resulting from the risk of Equine activities.
In addition:
 My child has permission to attend the DuPage County Overnight Horse Clinic, Saturday, June 8 through Sunday
June 9, 2013.
 I understand that a parent/legal guardian must attend the MANDATORY PARENT MEETING on MAY16
approximately 8:00 PM (after Just Say Nay club meeting) at the DuPage County Fairgrounds – 4-H Building in
order for my child to be eligible to participate in the Horse Clinic. No extra meetings will be held.
 I understand that as a parent/legal guardian of a participant, I am responsible to volunteer for at least one 2-hour
time slot during Horse Clinic event in order for my child to be eligible to participate in the Horse Clinic.
 I understand that in order for my child to be eligible to participate in the Horse Clinic, each child/family
participant will have a parent/legal guardian present at the clinic event. If accommodations need to be
made, I must contact Christine Birns at the Extension Office no later than Friday, May 31, 2013.
 I understand that each parent/legal guardian staying overnight must complete the on-line parent training
@ http://web.extension.uiuc.edu/4hchaperone/ prior to the Clinic dates.
 I understand that at no time should an adult and/or parent be allowed to ride or work the horse on the day of the
show.
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I understand that an adult owner/leaser for every horse must stay at the fairgrounds throughout the clinic, including
overnight.
I understand that no riding will be allowed except in designated areas. Elsewhere, the animal must be walked slowly
or led. Participants disregarding this rule will be disqualified from further competition.
I have instructed my son/daughter to follow the directions of the DuPage County 4-H Horse Committee,
Extension staff and adult chaperons while participating in this event.
I understand my child will be sleeping overnight at the DuPage County Fairgrounds.
Leashed dogs are welcome, but the committee has the right to ask any dog be removed if necessary All dogs
are the responsibility of the owner.
I understand that stalls are chosen by participants on a first come, first served basis. Stalls cannot be reserved prior
to Friday, June 7 at the voluntary Horse Clinic set-up. Only those who participate in this activity may reserve a stall at
this time. All other participants can reserve stalls on Saturday, June 8 or after the voluntary clinic set-up is over.
I understand that the DuPage County Extension personnel, Horse Committee or Fair Association do not assume
liability for loss or injury of any person, horse or property.
I understand that if my horse becomes ill or hurt, the Horse Committee has the right to call a veterinarian or to
send the horse home.
A Health Authorization form and fees must accompany registration form.
Proof of Negative Coggins test must be presented at check-in. No horse will be allowed to stay without
this paperwork.
I understand that any unsportsmanlike conduct by a participant, parent, and/or leader will jeopardize that participant’s
right to further participate in the clinic. At any time the Clinician and/or Show Committee may issue a warning. Upon
failure to comply with this warning, the participant shall be disqualified from further classes at the show.
I understand that Extension staff with support from the Show Committee will make final decisions regarding any
problems that arise not specifically covered by the above rules.
____________________________________________
Parent/Guardian Signature
__________________________
Date
PHOTO AND VIDEO RELEASE
I,
, grant the 4-H Youth Program, University of Illinois Extension, the permission to
disclose my (or my child's) identity and to reproduce and distribute videotapes, films, photographs, and transparencies of
me (or my child) and sound recordings arising out of documenting 4-H youth programs.
Signed this
day of
, 20
Name of Subject
Subject’s Signature
Address
City, State, Zip Code
Parent or Guardian’s Signature (if subject is a minor)
Address
City, State, Zip Code
.
Volunteer Roles:
All families with youth participating in the horse clinic and/or horse show are expected to volunteer for one or more task
(s) during these events. Please see the Volunteer Roles page for a listing of ways you can help.
Order of preference to help:
1st preference _________________
2nd preference _________________
3rd preference _________________
We have the following item/s that can be used:
Roaster
Crock Pots
Coolers
Canopy
Fees Enclosed:
$____________ Full Registration $50.00 (includes 3 meals, clinic and 1 stall)
$____________ $15.00 – Horse Project Member (without horse) for meals and observation of clinic.
$____________ Additional meal tickets amount for Non-participants. # of meals @ $3.50 each
Indicate how many for each meal: ____ Breakfast ___Lunch ____Dinner
(Sunday)
(Saturday)
$____________ Electric & Water Hook up for campers @ $10.00/day
$____________ Total $ - Enclosed (Make checks payable to: JUST SAY NAY)
No Refunds will be issued unless the event is cancelled. Please make checks out to: JUST SAY NAY
Registration form, participant’s health form and payment must be submitted by 4:00 pm, Friday, April 26
to the DuPage Extension Office or mailed directly to:
Cassi Williston
DuPage County Overnight Clinic Horse Committee
0N726 Morse St
Wheaton, IL 60187
Home - 630-690-5723
Cell - 630-363-8404
Questions about this event should be directed to:
Vicki Coffey, DuPage County Overnight Clinic Horse Committee, 630 414-6285 vkcoffey@sbcglobal.net
Cassi Williston, DuPage County Overnight Clinic Horse Committee, 630 363-8404 cassiwilliston@sbcglobal.net
Christine Birns, 4-H Coordinator, ext. 17 or cbirns@illinois.edu
UNIVERSITY OF ILLINOIS EXTENSION 4-H PROGRAM
YOUTH EMERGENCY MEDICAL INFORMATION
EVENT: _________________________________________________________________________________
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: (______) _________-______________
Address: ________________________________________________________________________________
Street
City
State/Zip Code
Name: __________________________________________________________________________________
Relationship
Home Phone: _ (______) _________-______________ Work 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.
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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_________________________________________
_________________________________________________________________________________
[ ]
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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: _______________________
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 preexisting conditions or self-inflicted injuries.
SIGNED:_____________________________________ DATE:__________________________
Parent or Guardian
The Assumption of Risk and Release form must also be completed. It can be found at:
http://web.extension.illinois.edu/dkk/dupage4h/1979.html. as the Horse Clinic Risk and Release Form.
Revised 4/00
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. The University of Illinois Extension provides equal
opportunities in programs and employment. *The 4-H Clover is Protected Under 18 U.S.C. 707.