4-H Youth Development
Operation: Military Kids
Youth Medical Care and Overnight Camper Information
YOUTH’S NAME:
BIRTH DATE:
AGE:
PARENT OR GUARDIAN:
MALE
FEMALE
COUNTY:
HOME ADDRESS:
HOME PHONE:
OFFICE PHONE:
CELL PHONE:
DOCTOR’S PHONE:
NAME OF FAMILY DOCTOR:
HEALTH INSURANCE COMPANY:
POLICY #:
IF YOU OR THE DOCTOR CANNOT BE CONTACTED, IN EMERGENCY NOTIFY:
NAME:
PHONE:
CELL PHONE:
SPECIAL
DCONSIDERATIONS
OES YOUR CHILD HAVE ANY SPECIAL DIETARY CONCERNS OR FOOD RESTRICTIONS?
PLEASE ADVISE IF CAMPER HAS NEVER BEEN TO AN OVERNIGHT GROUP CAMP SITUATION BEFORE, HAS EXPERIENCED A RECENT ILLNESS,
INJURY, OR SURGERY, OR HAS ANY ISSUES WITH BEDWETTING, MOBILITY, SOCIAL INTERACTION, OR OTHER HEALTH OR BEHAVIORAL CONCERNS:
CHECK THE APPROPRIATE BOX(S) BELOW IF PARTICIPANT IS SUBJECT TO ANY OF THE FOLLOWING CONDITIONS:
arthritis
asthma/respiratory problems
bladder disease
stomach problems
other (please specify):
bronchitis
ear infection
convulsions
frequent headaches
diabetes
fainting
allergies (please list):
heart trouble
home sickness
intestinal problems
kidney disease
seizures
sleepwalking
**TETANUS IMMUNIZATION - DATE OF LAST BOOSTER:
**STAFF OR CHAPERONES MAY ADMINISTER BENEDRYL, TYLENOL OR MOTRIN (ACETAMINOPHEN OR IBUPROFEN)
YES
NO**
MEDICATION
PROCEDURES
ALL
PRESCRIPTION DRUGS MUST BE CARRIED IN THE CONTAINER IN WHICH THEY WERE ISSUED (WITH MEDICAL ORDERS AND PHYSICIAN’S
NAME INTACT). OTHERS WILL NOT BE ACCEPTED.
BROUGHT TO 4-H PROGRAMS.
ONLY THE EXACT AMOUNT OF MEDICATION FOR THE LENGTH OF THE EVENT SHOULD BE
MY CHILD CAN HOLD ON TO AND ADMINISTER HIS/HER OWN MEDICATION.
YES
NO
SIGNATURE OF PARENT/GUARDIAN
MEDICATIONS - LIST ANY MEDICATIONS CAMPER TAKES, AND WHAT THEY ARE FOR. INCLUDE PRESCRIPTION AND NON-PRESCRIPTION
(SUCH
AS PAIN RELIEVERS, ASPIRIN, TYLENOL, ASTHMA INHALER, ETC.) PLEASE INCLUDE DOSAGES AND ANY SPECIAL INSTRUCTIONS:
SIGNATURE
STATEMENT
My
child is physically able to participate in this program. I understand that campers will be supervised, and that if a serious illness or injury
develops, medical and/or hospital care will be given; however, the sponsor is not responsible in case of accident or illness. I further understand
that in case of medical emergency we will be notified. In the event that I cannot be reached, I hereby give permission to the attending physician to
hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named on this Medical Care and Treatment
Form and do certify that the information set forth on this form is true and correct to the best of my knowledge. I will assume all financial obligations
incurred not covered by insurance. PLEASE SUPPLY A PHOTOCOPY OF YOUR CHILD’S INSURANCE CARD, FRONT AND BACK.
PARENT/GUARDIAN SIGNATURE:
EVENT:
DATE:
EVENT DATE:
University of N.H. Cooperative Extension is an equal opportunity educator and employer.
5/1/12
4-H Youth Development
Operation: Military Kids
Code of Conduct & Media Release
Operation: Military Kids (OMK) 4-H Event
Youth Code of Conduct
8.
As a participant in an Operation: Military Kids 4-H event, you
have the responsibility of representing the OMK program to the
public. You are expected to conduct yourself in a manner that
will bring honor to you as well as to 4-H and OMK. To do that,
you will need to:
1.
Attend all sessions in the planned program and
participate fully
2.
Follow hours and camp rules established before the
event begins. You are responsible for knowing the rules of
your events.
3.
Dress appropriately for each event.
4.
Use language and manners that will bring respect to
you and to the OMK program. You are responsible for
knowing what language and behavior is appropriate.
5.
Be in the assigned program area at all times (for
example: dorms, motels, etc.)
6.
Know that the use of non-prescribed drugs and
fireworks are illegal. Their use along with alcohol and
tobacco, are prohibited at all 4-H events.
7.
Model respect for other persons in public areas.
Treat program areas, lodging areas and transportation
vehicles with respect and care. You will be responsible for
any damage, theft, or misconduct in which you participate.
9.
Help other persons in your group have a pleasant
experience by making every attempt to include all
participants in all activities.
10.
Live up to your highest expectations for yourself so
you can return home proud of who you are and what you
have done.
Those who find themselves unable to conduct themselves
within the guidelines listed above may expect:
1.
To explain their actions to the adults in charge
2.
To accept the consequences of their actions
3.
To possibly be sent home immediately at their own
expense
4.
To possibly be excluded from participation in a future
4-H or OMK event or trip.
5.
To have the adults in charge notify parents/guardians,
Extension personnel and others to see that the actions
taken, in case of unacceptable behavior, are appropriate
for all concerned.
OMK 4-H Activity
Youth Permission and Release Form
for Participation in a 4-H OMK Activity of UNH Cooperative
Extension
(Print Name):
will be participating in
Event:
Date(s):
Description of this activity and transportation methods are
as follows: Multi-day Overnight Youth Event
We give permission for the above named youth to
participate. We understand the responsibilities, hazards,
and dangers inherent in participation of this activity,
including the transportation. We understand the Code of
Conduct.
We hold harmless the University of New Hampshire, its
trustees, officers, agents, employees, and volunteers
from and against all claims, demands, actions, and
causes of action for damages which may be sustained by
the above named youth or anyone else. This includes
personal injury, death or property damage, whether or not
the result of negligent acts or omissions on the part of the
University of New Hampshire. If the above named
youth’s participation in the activity causes damage to the
property of UNH Cooperative Extension, we agree to pay
the University for such loss.
****************************
I give permission for the use of quotes/photos/videos of
my child or myself: in the newspaper, newsletter, UNHCE
Operation: Military Kids web sites, on TV, or in other
ways to publicize 4-H or OMK events or activities, without
present or future compensation.
yes
no
I have read the Operation: Military Kids 4-H Code of Conduct and agree to live up to the expectations. I realize my failure
to do so could result in a loss of privileges during the event and/or in the Future.
Signature of Participant
Date
As the parent or guardian of (name)
, I have read the Operation: Military Kids
4-H Events Code of Conduct and will support the adults in charge in the performance of their responsibilities to see that
the
appropriate behavior is maintained.
Signature of Adult Parent or Guardian
Date
4-H Youth Development
Operation: Military Kids
Camp Family Agreement
Camper’s Name:
In signing this Agreement:
I have read the Camp Information and agree to comply with all the policies stated therein.
I hereby certify that the camper enrolled is in good health and subject to ordinary camp guidelines.
I agree to pay all camps fees and submit all required paperwork, including an accurate Youth Medical Care and Camper
Information form and the Youth Code of Conduct, prior to the beginning of my child’s session. I understand that the
Health/Medical Form MUST have a parent or guardian’s signature.
We, my camper and I, understand the responsibilities, hazards, and dangers inherent in participation in UNH 4-H Camps
programs and activities and in any travel arrangements, and permission is hereby granted for my child to participate. We
agree for ourselves and our heirs, to assume the risks and responsibilities of camper’s participation, and to release and
hold harmless the New Hampshire 4-H camps, the University of New Hampshire, its trustees, officers, agents, volunteers,
and employees, from and against all claim, demands, actions, and causes of actions for damages which may be sustained
or incurred due to personal injury, death, or property damage which may be sustained by my camper and arising from
her/his participation in camp activities, whether or not the result of negligent acts or omissions. We further agree to
defend, indemnify, and hold harmless the University of New Hampshire, its trustees, officers, agents, and employees, in
the event that, due to my camper’s participation in camp activities, anyone else sustains personal injury, property damage,
or death. In the event that my camper’s participation in the activity causes damage to the property of the University of
New Hampshire, we further agree to indemnify the University for such loss.
I agree to allow UNHCE Operation: Military Kids to act on my behalf in seeking routine or emergency medical care for
my camper, if needed while he/she is at camp. I authorize the emergency contacts listed on the Camper Application &
Camper Health Form to act on my behalf, should I not be readily available by phone.
I understand that UNHCE Operation: Military Kids Camps provide Accidental and Illness Insurance for all campers,
supplemental to the camper’s primary insurance, for accidents and illnesses occurring while at camp. Conditions existing
prior to the camper’s arrival at camp are not covered. I agree to pay any medical expenses arising from the accident or
illness in excess of policy limits or for illness or accidents not covered by UNH 4-H Camps’ Insurance plan.
Parent/Guardian Name (please print):
Parent/Guardian Signature:
Date:
Camper’s Signature:
Date
Operation: Military Kids, Pettee Hall GO5, 55 College Road, Durham, NH 03824-2536 Phone: 603/862-2297 Fax: 603/862-3271
www.nhomk.com
http://ceinfo.unh.edu
The University of New Hampshire Cooperative Extension is an equal opportunity educator and employer.
University of New Hampshire, U.S. Department of Agriculture and N.H. Counties cooperating
5/25/12