Great News! - Based on a study to learn what Missouri 4-H Camp Counselors gain from their experience, it’s proven that 4-H Camp Counseling is a develop- mental cornerstone for teens in the following areas: Time Management, Goal setting, and Problem-solving Identifying “Who am I”? Social skills, networking and teamwork Managing emotions Leadership skills and methods Strengthening career and education goals 62.7% said being a 4-H Camp Counselor helped them prepare for college 73% said being a 4-H Camp Counselor increased their desire to stay in school 65% said being a 4-H Camp Counselor had opened up job or career opportunities for them Being a Camp Counselor changed or confirmed career plans for a full one-third of the camp counselors in the study. Amazing! WOW!!! 4-H Camp Does all that?? YOU BET!!! 4-H Camp Counselor Application Cuivre River State Park Camp Derricotte, Troy, Missouri June 4-6 and 7-10, 2018 Immediate opportunities available for 4-Hers 14-18, wishing to enhance their leadership skills and talents through a very rewarding position as 4-H Camp Counselor. “Camp (counseling) has given me more options. . .I know I can follow my dreams” 07 Camp Counselor
Transcript
Great News! - Based on a study to learn what Missouri 4-H Camp Counselors gain from their experience, it’s proven that 4-H Camp Counseling is a develop-mental cornerstone for teens in the following areas: Time Management, Goal setting, and Problem-solving Identifying “Who am I”? Social skills, networking and teamwork Managing emotions Leadership skills and methods Strengthening career and education goals 62.7% said being a 4-H Camp Counselor helped
them prepare for college 73% said being a 4-H Camp Counselor increased
their desire to stay in school 65% said being a 4-H Camp Counselor had opened
up job or career opportunities for them Being a Camp Counselor changed or confirmed career plans for a full one-third of the camp counselors in the study. Amazing!
WOW!!! 4-H Camp Does all that?? YOU BET!!!
4-H Camp Counselor
Application
Cuivre River State Park Camp Derricotte, Troy, Missouri
June 4-6 and 7-10, 2018
Immediate opportunities available for 4-Hers 14-18, wishing to enhance their leadership skills and talents through a very rewarding
position as 4-H Camp Counselor.
“Camp (counseling) has given me more
options. . .I know I can follow my
dreams”
07 Camp Counselor
4-H Camping programs are a key part of youth development and can become instru-mental in developing youths’ leadership skills. Camping offers fun as well as the oppor-tunity to learn and apply many skills that can serve young adults well over their lifetime. One of the guiding principles of experiential education is that people learn best by do-ing something. In 4-H Youth Development we believe leadership development skills should not be learned in a vacuum, but rather are best learned in context with other events or activities. Youth are then encouraged to find ways to transfer all of what they have learned to other experiences, programs and with other groups of people.
4-H Members ages 14-18 as of January 1, 2018 (non 4-H youth may apply if
counselors are needed). Turn in forms by deadline.
Serve as a positive role model for 4-H campers age 8-13, lead games, activi-
ties, manage small groups of youth. Listening, sharing, guiding, and teaching
campers.
June 4-6 (Counselor Training) and 7-10 (4-H Camp), 2018; must attend train-
ing. Counselors will be selected based on application, potential and perfor-
mance during training. Note: Counselors will not come home between training
and camp. We will have one night at camp before campers arrive.
Cuivre River State Park, Camp Derricotte, Troy, Missouri (secluded group
camp facility).
Serving as a camp counselor will give you many opportunities to develop your
leadership skills and help prepare you for the workplace. You will learn and
practice many valuable techniques for managing groups, motivating and en-
gaging youth in activities, and for making camp a memorable experience for
the campers. The skills you will gain as a counselor will serve you throughout
your life.
$165.00 Due May 1. Transportation is on your own for Counselor Camp. We
are working on transportation to camp. If group transportation is not an op-
tion, can you provide carpooling: Yes No. If yes, how many youth with
luggage? . (Adair County Only—Limited United Way funding may be
available to offset the camp fee for Adair County 4-H Camp Counselors.)
Fill out counselor registration, health statement, and counselor application.
Forms due May 1.
Who:
What:
When:
Where:
Why:
Cost:
How:
NEMO 4-H Camp 4-H Youth Health Statement, Parent Consent, Agreement and Event Acceptance Form
Complete the Entire Form - Do not alter the form in any manner.
Name _______________________________________ Date of Birth _______________ 4-H age (as of 1/1/18) _______
Gender M____ F____ County _______________________________
Parent or Guardian contact information: Parent ’s Name ________________________________________________
Home # _____________________ Work # ____________________________ Cell # __________________________
Insurance Co/Policy # _____________________ Insurance Co. Name ______________________________________
The better we, as Camp Directors, understand your child, the better we can help him or her make the most of his or her camp experience. While this information is held in strictest confidence, if you would rather discuss this with the Youth Specialist in person or by phone, write your name and phone number here: Your Name_________________________________ Relationship to child ___________ Phone number ____________
In the last year has your child suffered from any significant stress-related problems, such as a recent death in the family,
illness or personal trauma? ___ No ___ Yes. Please, explain: _____________________________________________
My child has my permission to swim under the supervision of qualified lifeguards: Yes No
Date of last Tetanus immunization? _____________________________
May your child be given pain relievers (i.e., Tylenol, Motrin, etc.) Yes No
The Northeast Missouri 4-H Camp Committee has a “no nit” policy concerning head lice. I understand that if head lice or nits are found on my child, I will be responsible for taking my child off camp premises immediately. Initial here ______ Medical Release: If necessary, I approve of officials taking my child, to the nearest doctor or hospital. I further understand that, should a health problem arise, I will be notified. If I cannot be reached by phone, such medical treat-ment, including surgery, as deemed necessary by competent medical personnel, would be rendered.
____________________________ has my permission to attend 4-H Camp. Continued on back …
I have answered all questions honestly and to the best of my knowledge. I understand that he/she will remain in camp for the full session unless excused by camp officials. During camp the camper will be under the supervision of camp officials and subject to camp regulations. I will not hold camp officials liable for sickness, injury in camp or while in route to or from camp. Date _____________ County _______________ Parent/Guardian Signature__________________________________ CAMPER ACCEPTANCE: The Missouri 4-H program and the area camping program are open to all youth that meet age and eligibility guidelines. It is important that the camp program be conducted in such a way that provides the safest possible environment for all. Every attempt will be made to work with the parents or guardians of potential campers with special health conditions or with behavioral or emotional management requirements, to work out ways to involve the camper where possible. Potential camp applicants that have medical or behavioral conditions that are beyond the train-ing, available equipment or time constraints of the camp staff may not be accepted in the camp program or, they may be accepted with restrictions. Effort will be made to help family locate a camp that may be better suited to meet their child’s needs.
EVENT ACCEPTANCE: Education events and activities are coordinated by the University of Missouri 4-H Youth Devel-opment Programs. All participants must observe the following guidelines for conduct:
1. Participate fully in all sessions. 2. Show respect for property/facilities used during the event and assume financial responsibility for any damages
caused. 3. Follow the established agenda and expectations for behavior, including being in their own rooms at the announced
curfew. 4. Use appropriate language and wear acceptable clothing at 4-H activities and events. 5. Use no alcohol, stimulants, non-prescription drugs or tobacco products.
I understand and accept the responsibility for following the above guidelines and understand that failure to do so will re-sult in dismissal from the event or activity. Further, I accept financial responsibility for damages to property or materials, travel costs and/or program costs that might result from violation of this agreement. I understand and agree that in con-sideration of the acceptance in these activities, we release 4-H, the Curators of the University of Missouri, their respec-tive officers, agents and/or employees from all liability and loss (including court costs and attorney fees) resulting from any property damage, personal injury and bodily injury including death to me in the course of these events. We will be bound by all rules and regulations while participating in said events.
CHILD PHOTO AUTHORIZATION: I authorize the University of Missouri to make pictures and sound recordings of my child and use the same in any form for its purposes and consent that the pictures and recordings may be copied, published, telecast or broadcast for such purposes together with descriptions and editorial statements. The University of Missouri is not responsible for third party photographs.
Both youth and parent (guardian) must sign this form. If you choose to have this form notarized, your signature must be witnessed by the Notary Public. I understand if I do not have this health statement and consent form notarized, it could
cause a delay in my treatment.
Notary Optional (some hospitals require) State of Missouri, county of . My commission expires _____________
Subscribed and sworn to before me on this _____ day of ____________________, 20__ Notary Public Signature
4-HMU is an Equal Opportunity Institution. For concerns about access or opportunity, contact your local MU Extension center or call 573-882-7430. The University of Missouri complies with the guidelines set forth in the Americans with Disabilities Act of 1990. If you have special needs as addressed by the Americans with Disabilities Act and need assistance with this or any portion of the enrollment process, call 573-882-2719. Reasonable efforts will be made to accommodate your special needs. Revised 4/15 copy form as needed.
_____________________________________________ Signature of Youth
_____________________________________________ Date
_____________________________________________ Signature of Parent/Guardian
_____________________________________________ Date
All signatures and requested information on this and the attached pages must be completed and signed to successfully apply as a camp counselor. Registrations are taken first come, first served. A second bus will be available to 4-H Camp IF there are enough riders to cover the cost. Register early to get a seat on the bus!!
Please return with camp health form, application, and check or money order by May 1 to:
4-H Counselor Camp, 503 E. Northtown Rd., Kirksville, MO 63501.
Make checks payable to Adair County Extension/4-H. Returned checks are subject to a $20.00 fee.
Registration Due May 1!
No refunds after May 15.
This form CANNOT be faxed or emailed if paying by credit/debit card. It must either be mailed or presented in person. Thank you.
I authorize University of Missouri Extension of Adair County to make a one-time charge to my account indicated below for $ on or after May 1, 2018 for full payment of 4-H Camp fees.
Cardholder Name: Email
Billing Address City, state, zip
Phone Card Type (circle): Visa Mastercard Discover AMEX
Credit Card Number: Expiration Date:
Signature Date
A confirmation email will be sent to the address provided above when your debit/credit card has been charged. For security purposes this section of the form will be shredded.
Fee structure Cost
Camp Fee $152.00
Rush Fee ( ) ADD $20
Check # ____ Total No refunds after May 15
Camp t-shirts (Camp t-shirts not available
after May 1 registration deadline.)
Youth S (6/8) ______
Youth M (10/12) ______
Youth L (14/16) ______
Adult S __ __
Adult M __ __
Adult L __ __
Adult XL __ __
Adult XXL __ __
Return by May 1
4-H CAMP COUNSELOR APPLICATION CAMP DATES: Counselor Camp – June 4-6 4-H Camp – June 7-10 Name: Age (as of 1/01/18)
4-H Club: Phone: Cell #
Address: City: Email:
How many years have you attended 4-H Camp as a camper?
How many years have you been a 4-H Camp Counselor?
How many years have you helped with Clover Kids Day Camp?
List any other "counselor" type activities you have performed at any other youth camp or day camp.
Facilities and services are available to all without regard to race, color, national origin, age, sex, or handicap. For concerns about access or opportunity call (636)583-5141.
Counselor Application page 2
NORTHEAST MISSOURI 4-H CAMP COMMITTEE COUNSELOR POLICIES AND AGREEMENT
As a 4-H Camp Counselor, I… …understand that campers look to me as a role model. How I conduct myself and how I treat camp-
ers will set the tone and camp culture for years to come. …will show my most mature, caring, positive and responsible behavior -- toward campers, other
counselors, camp staff, MU Extension Camp Directors, staff, volunteers, and visitors. …understand that camp is for the camper -- and as a counselor, I will put my own desires aside for
the good of camp and the campers. …will do my best to ensure that every camper participates and has a positive camp experience. …will remain with the campers in my care at all times (unless directed otherwise by the MU Exten-
sion Camp Director); I will manage and supervise campers in my care using techniques taught to me during Counselor training. I will ask for guidance from MU Extension Camp Director if I am feeling unsure or if camper(s) are not cooperating.
…understand that pranks are not tolerated at camp. …will observe evening curfews (being in my assigned cabin, quiet and lights out at prescribed times
as stated by MU Extension Camp Director), and will not leave my cabin unless to contact MU Ex-tension Camp Director or health aide.
…will conduct camper roll call by name, each night, in my cabin at lights out to ensure all campers
are in place and accounted for. …I will follow all camp rules, and guide my campers to do the same; including but not limited to: fol-
lowing the camp program, being on time to all activities, wearing shirt and shoes at all times; walking or skipping only; displaying good dining hall etiquette; keeping my belongings neat and orderly; keeping camp clean and litter-free; wearing my nametag around my neck; refraining from public or private displays of affection, etc.
…will refrain from engaging in any illegal or immoral behavior, including but not limited to; drinking,
smoking, using drugs, having fireworks, open flames, matches or lighters in camp; posting any negative or revealing comments concerning campers or other counselors online, etc.
…understand that I am to be in the same sex’s cabins only. (Girls in girls’ cabins/boys in boys’ cab-
ins only). …understand that the only time I am to be in the opposite sex’s village is when accompanying
campers or leading a camp program in that village’s lodge. …understand that I am not allowed in camp staff cabins (with the exception of health aide cabin for
medical reasons or when escorting a camper). …will not use my cell phone at camp. I agree to turn it off, stow it out of sight, and leave it off for the
duration of camp, unless directed otherwise by the MU Extension Camp Director. I agree that if I need an alarm clock, I will bring one. If I need a watch during the day, I will bring one. I under-stand my cell phone will be confiscated and my parents contacted if I am found to have used my cell phone for any reason during camp.
~over~
…understand that I have a responsibility to, and guarantee that I will, talk confidentially with the MU
Extension Camp Director if I witness a camper or counselor bullying, harassing or otherwise mis-treating others.
…will always consult with MU Extension Camp Director before taking any action that may be outside
my responsibility or authority (such as allowing a camper to call home.) …will not take pictures at camp of campers, staff or others that could embarrass or humiliate them.
Further, MU Extension Camp Directors trust my judgment in posting online only pictures that por-tray campers/counselors in a positive way. I understand that MU Extension Camp Directors have the authority to ask me to remove any online comments, pictures, etc. that are reported to them as being defamatory, etc.
…will ask for, and receive, written permission from the MU Extension Camp Director before creating
a camp ‘group page’ or similar page on any social networking site. Likely, the MU Extension Camp Director will request administrator rights, if permission is given to me to create the group.
…will respect and preserve camp and park facilities and nature environment. I understand that I will
be responsible for making restitution (financial and otherwise) for any damages I cause. ...will not have visitors during counselor training or 4-H camp. …will commit to be at Counselors’ training and 4-H Camp for the entire duration, unless I have re-
quested and have been given prior approval by the MU Extension Camp Director. I have read and understood the above policies. I have discussed these with my child and agree to support MU Extension Camp Director in carrying out these policies. I understand that failure to ad-here to these policies can result in immediate dismissal from camp, legal procedures, etc. Further, I accept financial responsibility for damages to property, materials, travel costs and/or program costs which might result from violation of this agreement. ________________________________________ ___________________ Parent/Guardian’s signature Date I have read and understood the above policies. My parent has discussed these with me and I agree to support the MU Extension Camp Director in carrying out these policies. I understand that failure to adhere to these policies can result in immediate dismissal from camp, legal procedures, etc. Fur-ther, I understand that my parents and I are financially responsible for damages to property, materi-als, travel costs and/or program costs which might result from violation of this agreement. Most im-portantly, I understand the crucial role I play in making camp a positive experience for young people and will conduct myself with the highest regard for camper health, safety, and happi-ness. ________________________________________ ___________________ Counselor Applicant’s signature Date
