Register by Wednesday, June 26, 2019 or until full - Refunds until June 26, 2019

PDF Form to print

Date:

July 16-19, 2019 (Tuesday-Friday)                

Location:

Loon Lake 4-H Camp – Big Fork, MT

Age:

4-H Age 8-12 (4-H Age is age of youth on Oct. 1, 2018)

Cost:     

  • $115 for current 4-H members
  • $145 for non 4-H members
  • Free for Counselors & Chaperones

Cost includes transportation, nine meals, snacks, cabin bunk with mattress, hot showers, canoeing, swimming, campfires, fun workshops, games, and dance.

Questions?  375-6611

Register: Return form with payment to:                                                

Ravalli County 4-H Council                                                            

215 S. 4th Street Ste G                                                                    

Hamilton, MT 59840           

4-H Scholarships available: complete scholarship request form  with application.  Secure spot with $10 deposit per youth.  Scholarship recipients will be notified as soon as possible.

 

Name:  _________________________________________________________________

 

Address:  ___________________________

 

City and Zip:  ________________________

 

Phone:  _____________________________

 

4-H Age: _________     DOB:  __________

 

Email:  ______________________________

 

Male        Female    (circle)

 

What kind of swimmer are you?  

 

  Poor   Fair   Good   Excellent   (circle)

 

PARENT:  Can your child sleep on the top bunk?

 

 Yes         No     (circle)

 

CAMPER: One friend I would like in my cabin:

Kid T-shirt size: S        M       L       XL

 

Adult T-shirt Size:   S        M       L       XL

I would like to be picked up at:    (circle one)

 

 

Hamilton – Kmart Parking Lot (8:15 AM)

 

Florence – Town Pump Lot (9:00 AM)


Code of Conduct

  1. Have fun and be safe! Participate in everything!  Be on time!
  2. Wear your name tag (except when sleeping, swimming or showering)!
  3. Drink water regularly. A refillable water bottle will be provided!
  4. Be at the dock ONLY when lifeguard or canoeing instructor is present!
  5. Stay on the premises!
  6. If you feel sick, tell the camp staff or an adult!
  7. Girls only in girls' cabins, Boys only in boys' cabins!
  8. Wear appropriate clothing: Swim suit in the lake; appropriate clothes on at all times, hat off in dining room; shoes on when walking outside!
  9. Quiet and cabin time is from 10:30 pm to 7:00 am for sleeping and for being good neighbors!
  10. No: Pranks! Fireworks! Foul Language! Alcohol!   Illegal Drugs!   Tobacco of any kind!  Items that could cause harm to other campers!
  11. Follow the direction of camp leaders!

I agree to follow the Code of Conduct.

Date and Signature of Applicant:  _____________________________________________ 

I understand that in the event of misconduct, the applicant will be sent home at the parent's expense.

Date and Signature of Parent or Guardian:  ___________________________________

There will be a CPR and First Aid holder and a certified lifeguard at camp.

All camp participants must complete a Medical Release Form for 4-H Youth & Adults.

If your child requires a prescription or over the counter medication while at camp, a Physician Order Form must be signed and sent to the Extension Office prior to giving the child the medication at camp. You may have your health care provider fax the form to the Extension Office at Fax: 375-6606.

Please indicate here if you will submit a Physician Order Form for Youth:      Yes         No     (circle one)

 

List special diet or food restrictions:

 _____________________________________________________________________________

*Loon Lake 4-H Camp Staff can only accommodate requests for Gluten Free Diets. Any other dietary restrictions are not accommodated by staff. Parents need to send food for their child and the staff will prepare any food given to the kitchen and store in the kitchen.

Describe any physical restrictions:__________________________________________

Is there other information we should know about the applicant to ensure his/her well-being?__________________________________________________________

In case of medical emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for the applicant.  In case of minor emergency, I hereby give permission for the camp CPR and First Aid provider or qualified camp staff to administer first aid. Parents will be notified of serious physical conditions requiring off-site medical attention.

I give permission for the camp staff to administer nonprescription medications to my child (check all that apply):

           Acetaminophen (Tylenol),            Ibuprofen (Advil),            Cough syrup,           Antacid (Tums, Mylanta),            Antihistamine (for allergic reaction)


Media Release

MSU Extension 4H would like to use photos or video of the participant during 4‐H events or activities to use in press releases and other publicity. The photo or film may be used for the following purposes:

  • Website
  • Press Release
  • News Story
  • Marketing Materials
  • Other

CONDITIONS OF USE:

  1. We will not use personal details or full names (first name and last name) of any participant in a photograph on our web site.
  2. We will not include personal e‐mail or postal addresses or telephone numbers on our web site or in other printed publications.
  3. We may use the name of the child in accompanying text or a photo caption.

          I DO authorize the use of photos or video of the applicant at 4H events or activities.

          I DO NOT authorize the use of photos or video of the applicant at 4H events or activities.


Consent to Participate

Description of Event:  RAVALLI COUNTY 4-H CAMP. This four to five day event held at Darrell Fenner Loon Lake 4-H Campprovides a variety of workshops such as crafts, canoeing, games, dance, campfires, archery, and swimming.  Campers sleep in cabins with an adult chaperone and teen camp counselor(s).  Transportation to and from camp is provided by school bus. 

 

Consent: I/we understand the program and activities which are involved, consent to my/our child's participation, and agree to have my/our child abide by all the applicable rules, regulations and directions specified by the adult leader(s).  In consideration of my/our child's being permitted to participate in the Ravalli County 4-H Junior Camp, I/we hereby assume all the risks associated with participation and necessary travel.  I authorize MSU/Ravalli County Extension Office to provide information to the Darrell Fenner 4-H Camp staff to ensure the safety of the child. We understand that if we have any questions about this event and its activities, we can secure more information before signing this consent form by calling the MSU/Ravalli County Extension Office, 375-6611.  I have read, consent, and agree, individually and, as a parent or guardian of the minor named above, to the foregoing terms and provisions. I warrant that I am of full legal age and have every right to contract for the minor in the above regard.

I agree to follow the Code of Conduct.  Date and Signature of Applicant:

 _________________________________________________________________________

I understand that in the event of misconduct, the applicant will be sent home at the parent's expense.

Date and Signature of Parent or Guardian:

 ___________________________________________________________________________


Medical Release Form for 4H Youth & Adults

PARTICIPANT INFORMATION:                                                                                                             

Name: _______________________________________County: _________________________

Address:_______________________________________________________________________

Name of Parent or Legal Guardian: (YOUTH ONLY): ________________________________________________

Primary Physician: _________________________________ Phone: ___________________

Dentist: ____________________________________________ Phone: ___________________

IN CASE OF EMERGENCY:                                                                                             

Primary Contact: ________________________ Phone: ______________________________

Relationship: ______________________City: ___________________ State: ______________

Alternate Contact: ________________________________ Phone: _____________________

Relationship: _______________________City: ___________________ State: _____________

INSURANCE INFORMATION                                                                                

Name of Insurance Carrier:____________________________________________________

Policy Holder Name: ______________________ Policy #: __________________________

Date of Last: Tetanus Shot: _________ Polio Shot: _________

Mumps Shot: _________ Measles Shot: _________  Rubella Shot: __________

Medical Information: (check all that apply and explain if necessary)

□ Stomach or Intestinal problems 

Diabetes or hypoglycemia (low blood sugar)

□ Nervous disorder (convulsions, epilepsy, dizziness, etc)   

□ Respiratory problems

□ Heart Disease                                                                            

□ Any allergies to medication

□ Any allergies to food or plants                               

□ Special diet or food restrictions

□ Are you currently under a doctor's care?                           

□ Are you currently taking medications?

□ Are there any physical restrictions or medical problems that may require special considerations?

_________________________________________________________________________________

_________________________________________________________________________________

AUTHORIZATION FOR TREATMENT (YOUTH ONLY)                                

I, ________________________________ do herby give permission to _______________________________ to seek and obtain any medical care necessary for my child _________________________________________ .

Parent/Guardian Signature _____________________________ Date ______________

PARTICIPANTS                                                                                                 

To the Best of my knowledge, accurate information has been provided in all areas of this form.

Participant Signature (youth/ adult) _________________________ Date _____________

IF YOUTH: Parent/Guardian Signature _____________________ Date ______________


Physician Order Form for Youth

Permission for medication to be given at:  Ravalli County 4-H Summer Camp, July 16-19, 2019

This form is required if a camper requires a prescription or over the counter medication while at camp. It must be sent to the MSU/Ravalli Extension Office prior to giving the child the medication at camp. You may have your health care provider fax to the MSU/Ravalli County Extension Office at fax: 375-6606.

Questions? Please call 375-6611 or ravalli@montana.edu

Name of camper:                                                                       DOB:                         

Diagnosis:                                                                                                                                          

Medication:                                                                             Dosage:                           

Purpose of medication:                                                                                                  

Time of day medication is to be given:                                                                        

Possible side effects:                                                                                                                                                                                                                                                   

Additional instructions:                                                                                                                                                                                                                                              

Diagnosis:                                                                                                                        

Medication:                                                       Dosage:                                              

Purpose of medication:                                                                                                  

Time of day medication is to be given:                                                                        

Possible side effects:                                                                                                                                                                                                                                                   

Additional instructions:                                                                                                                                                                                                                                             Date                                        Signature of Physician or Health Care Provider       __                                                                      Name of Health Care Practice

I request that MSU Extension/Ravalli County 4-H Summer Camp Staff designated staff administer the above medication to my child at camp as ordered. I will deliver the medication in the original package or prescription bottle, with the name of the camp, the name of the medication and the dosage to the Camp Staff at arrival to the camp bus.

         ___________________                                                                  

Date                                        Signature of parent/guardian

Montana State University Extension Service is an ADA/EO/AA/Veteran's Preference Employer and educational outreach provider.