June 11-12, 2011
When: Saturday, June 11 (stay over Saturday night). Clinic ends at 12:00 pm Sunday, June 12.
Where: DuPage County Fairgrounds, 2015 W. Manchester Road, Wheaton, IL 60187
Check in time is 7:00--8:00 am on Saturday. The Saturday activities will begin at 8:30 am with a mandatory
parent and participant meeting followed by start of the clinic.
Saturday Clinic –Lisa Leach will act as the primary clinician. Lisa has been involved with horses for over 30 years.
She has been professionally training for over 15 years and was one of the Midwest Mustang Challenge trainers in
2008. She has been a horse show judge for thirteen years. She holds judges cards for TWHEBA (all divisions),
WFQHA, PAC, Illinois, Indiana, and Iowa open and 4-H shows. Lisa has been a riding instructor for 18 years. She is
the Grundy County Horsebowl and Hippology coach and has been for the past thirteen years. Lisa uses great
patience and care when training horses and does not use "quick shortcuts". She will patiently explain what you and
your horse can do to achieve the optimum results.
The clinic format will be similar to last year with a mock show. Both English and Western classes will be offered. For
each class, Debbie will place the class based on performance and give feedback to participants with 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)
that may include: how to handle your horse on the ground, grooming, what does a Farrier do, gaming strategies,
showmanship training. There will also be some down time for a craft activity and the Clinician has offered to present
a Power Point Presentation, if time permits.
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 29th. Send registration form, health form, and fees for the clinic and
additional meal tickets to DuPage County Extension Office.
Volunteers are necessary to make this event possible. Each family must volunteer if their son/daughter is
participating.
IMPORTANT MANDATORY PARENT MEETING
MAY 19 approximately 8:00 PM
(after Just Say Nay club meeting)
FAIRGROUNDS – 4-H BUILDING
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
All families participating in the horse clinic and horse show must volunteer to help with one or more of the
following tasks.
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 11 & 12) – 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 and horse show (June 11 & June 25) – We need people to help at the checkin table to give instructions and information. At the show, workers will give the exhibitor their number and
schedule of events along with other instructions. Sign up for one day, both days, or both events.
3. Scratch table workers (June 25) – We want to set up a table during registration of the horse show to handle
any class scratches by exhibitors. This will prevent the registration line from getting too congested.
4. Check-out persons (June 12 & 25) – 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).
5. Clinician representative (June 11) – This person will ensure that our clinician has water, sunscreen, umbrella,
breaks, etc.
6. Trail/dressage & jumps and gaming equipment (June 11, and June 25) – We need crews to set up and
remove trail obstacles, dressage arena and jumps. Sign up for one day, both days, or both events.
7. Judge representative (June 25) – This person will ensure that the judge has water, sunscreen, umbrella, etc.
8. Ring steward (June 25) – This person will stay in the arena with the judge during the horse show and will be
responsible for communicating to the announcer what the judge wants the exhibitors to do. The steward will also
handle any situations that may come up in the ring and show the exhibitors where to line up, etc.
9. Gate keepers & judging card handler (June 25) - We need people to stand by the arena gate to let exhibitors
in and out. We also need someone to stand in between the trailer and the arena to pass the judge’s card to the
announcer’s stand.
10. Donations (June 11 & 12) - Help get food donations from local merchants prior to Clinic and pick up for Clinic
days.
11. Help with games (June 11 & 12) – Help plan, organize, and run the horse games.
Anyone who has a trailer for hire (June 11, 12 and/or June 25) - 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 11, 12 and 25. A canopy is also needed.
2011 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 is 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.
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.
DuPage County 4-H
Overnight Horse Clinic Registration Form
Due: Friday, April 29 by 4:00 pm to the Extension Office
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 11 through
Sunday June 12, 2011.
 I understand that a parent/legal guardian must attend the MANDATORY PARENT MEETING on MAY 19
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.
 I understand that as a parent/legal guardian of a participant, I am responsible to volunteer for at least one 2hour time slot during Horse Clinic event in order for my child to be eligible to participate in the Horse Clinic.
 I understand that each child/family participant will have a parent/legal guardian present at clinic events,
including throughout the night at horse clinic, in order for my child to be eligible to participate in the Horse
Clinic. If accommodations need to be made, I must contact Christine Birns at the Extension Office no later
than Thursday, June 2, 2011.
 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.
 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.
 I understand that dogs must be on a leash and will not be allowed on the fairgrounds overnight.
 I understand that stalls are chosen by participants on a first come, first served basis. Stalls cannot be reserved
prior to Friday, June 10 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 11th or after the voluntary
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clinic set-up is over.
I understand that participants must clean out stall areas before animals are released. In addition, each member
will be assigned an area of the grounds to be cleaned. No animals may leave grounds until stall area has been
checked by member of Show Committee.
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
I give the Extension office permission to give my contact information to the DuPage County 4-H Horse Committee so
that they may follow-up with my family regarding this event.
_____________________________________________
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 _________________, Dates I can do this task___________________________
2nd preference _________________, Dates I can do this task___________________________
3rd preference _________________, Dates I can do this task __________________________
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 University of Illinois Extension)
No Refunds will be issued unless the event is cancelled.
Registration form, participant’s health form and payment must be submitted by 4:00 pm, Friday, April
29th to the DuPage Extension Office.
DuPage County Extension
1100 E. Warrenville Road, Suite 170
Naperville, IL 60563
630/955-1123 (phone)
630/955-1180 (fax)
Questions about this event should be directed to:
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/dupage/4hyouth620.html. There you will find the 2011 Horse Clinic
Risk Form.
Revised 4/11
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.