JOHNSTON COUNTY 4H 2017 SUMMER FUN SCHEDULE 4-H Summer Fun is a collection of fun educational workshops and hand-on activities planned especially for Johnston County youth. This program is designed to give youth positive learning opportunities and focus on developing life skills. 4-H activities are open to youth ages 5-18 (as of the date of the camp), but please pay close attention to class ages, descriptions, fees, dates and times. Youth do NOT have to be in 4-H to participate in Summer Fun Registration Date/Time Registration begins for Johnston County 4-H members April 19 th , then all youth May 1 st . Payment Payment is due with registration forms to reserve a space. June 1 st is the last day for registration. Clover Cash can be used for any Summer Fun Events. Youth/parents should check their clovercash balance here go.ncsu.edu/clovercashbalance Checks or money orders should be made payable to, Johnston County 4-H. There is a $10.00 service charge for returned checks. *We do not accept cash. Policy and Procedures The following forms MUST be filled out or on file for each child: 4-H Enrollment form, Code of Conduct (read and initial the enrollment form), Summer Fun registration form, and NOTARIZED Medical Release form turned in not postmarked by June 1 st or you forfeit your child’s space in the camp. Registration ends June 1 st . All registration fees and necessary forms should arrive in the 4-H office by June 1 st (not postmarked) mailing address: Johnston County Cooperative Extension 4-H Summer Fun Program 2736 NC 210 Hwy Smithfield, NC 27577 No registrations will be accepted by telephone. Refunds/Cancellations *All fees are non-refundable unless the class is cancelled. *Refunds for canceled workshops will be processed within 3 weeks after cancellation notice. In the event of a cancellation, you will be notified as soon as possible. *All classes must have a minimum of 5 students or the class will be cancelled. Punctuality *Parents/guardians must come into the 4-H office/Livestock Arena to sign their child/children in and out each day of camp. Participants should arrive no more than 10 minutes prior to the start time of each activity, and should be picked up no later than 10 minutes after the activity is scheduled to end. There will be an early/late fee ($1.00 per minute) for youth who arrive more than 10 minutes early and are picked up more than 10 minutes late. When transportation is provided to another location for a program, participants who arrive more than 5 minutes late will be left and no refund will be given. *Because of car seat laws, transportation for 5-7 year olds will not be provided by 4-H. If you have questions, please contact Angie Faison, 4-H Secretary, at 919-989-5380.
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JOHNSTON COUNTY 4-H 2017 SUMMER FUN SCHEDULE 4-H Summer Fun is a collection of fun educational workshops and hand-on activities planned especially for Johnston County youth. This program is designed to give youth positive learning opportunities and focus on developing life skills. 4-H activities are open to youth ages 5-18 (as of the date of the camp), but please pay close attention to class ages, descriptions, fees, dates and times.
Youth do NOT have to be in 4-H to participate in Summer Fun
Registration Date/Time Registration begins for Johnston County 4-H members April 19th, then all youth May 1st.
Payment Payment is due with registration forms to reserve a space. June 1st is the last day for registration. Clover Cash can be used for any Summer Fun Events. Youth/parents should check their clovercash balance here go.ncsu.edu/clovercashbalance
Checks or money orders should be made payable to, Johnston County 4-H. There is a $10.00 service charge for returned checks. *We do not accept cash.
Policy and Procedures The following forms MUST be filled out or on file for each child: 4-H Enrollment form, Code of Conduct (read and initial the enrollment form), Summer Fun registration form, and NOTARIZED Medical Release form turned in not postmarked by June 1st or you forfeit your child’s space in the camp.
Registration ends June 1st. All registration fees and necessary forms should arrive in the 4-H office by June 1st (not postmarked) mailing address:
Johnston County Cooperative Extension 4-H Summer Fun Program 2736 NC 210 Hwy
Smithfield, NC 27577
No registrations will be accepted by telephone.
Refunds/Cancellations *All fees are non-refundable unless the class is cancelled.*Refunds for canceled workshops will be processed within 3 weeks after cancellation notice. In the event of a cancellation, youwill be notified as soon as possible. *All classes must have a minimum of 5 students or the class will be cancelled.
Punctuality *Parents/guardians must come into the 4-H office/Livestock Arena to sign their child/children in and out each day of camp.Participants should arrive no more than 10 minutes prior to the start time of each activity, and should be picked up no later than 10 minutes after the activity is scheduled to end. There will be an early/late fee ($1.00 per minute) for youth who arrive more than 10 minutes early and are picked up more than 10 minutes late.
When transportation is provided to another location for a program, participants who arrive more than 5 minutes late will be left and no refund will be given.
*Because of car seat laws, transportation for 5-7 year olds will not be provided by 4-H.
If you have questions, please contact Angie Faison, 4-H Secretary, at 919-989-5380.
June 12th 9:00 a.m.- 12:00 Noon Location: Meet at 4-H Office or Howell Woods Spend the morning at Howell Woods and learn the significance of wildlife in our area. See if you can detect which of our wild “neighbors” has been on the prowl, where they went, and what they might have been doing. We will also make plaster molds of animal tracks and observe the animals at the Howell Woods museum. Bring sunscreen, drinks and snacks. Closed toe shoes only. Transportation available, if riding from the 4-H Office, we will leave at 8:30 and return by 12:30p.m. Instructor: Meredith Massengill of Howell Woods Ages: 8-13 Cost: $20 Max: 15
Geocaching @ Howell Woods
June 14th 9:00 a.m.- 12:00 Noon Location: Meet at 4-H Office or Howell Woods Want to go on a Treasure Hunt? With so many trails at Howell Woods, it's a perfect opportunity to go hunting for treasures by geocaching. Students will gain an understanding of using GPS. Bring sunscreen, drinks and snacks. Closed toe shoes only. Transportation available, if riding from the 4-H Office, we will leave at 8:30 and return by 12:30p.m. Instructor: Meredith Massengill of Howell Woods Ages: 8-13 Cost: $20 Max: 15
Fishing Frenzy
June 15th 9:00 a.m. – 12:00 Noon Location: Meet at 4-H Office or Howell Woods This beginner fishing class will introduce you to native fishes and provide you with tricks and tips for freshwater fishing. Poles and bait are provided, but participants are welcome to bring their own! Bring sunscreen, drinks, and snacks. Closed toe shoes only. Transportation available, if riding from the 4-H Office, we will leave at 8:30 and return by 12:30p.m. Instructor: Meredith Massengill of Howell Woods Ages: 9 & up Cost: $20 Max: 15
Blue Devil's Day
June 19th 1:00 p.m. – 5:30 p.m. Location: Meet at 4-H Office Participants will visit Duke University. We will have an information session and tour of the campuses. Dress casual, but in compliance with the 4-H Code of Conduct and wear comfortable walking shoes, apply sunscreen or bring it with you. Bring any snacks/drinks that you think you will need while we are there. Instructor: Lori McBryde Ages: 9th grade & up Cost: $10 Max: 12
Jr. Master Gardener Camp
June 19th - June 23rd 9:00 a.m. – 12:00 Noon Location: 4-H Office Become a Jr. Master Gardener and learn about flowers, plants, and so much more! Learn how plants help our environment and how our environment affects plants and us. Discover new and interesting facts about worms and insects as well as other creatures that inhabit our soil and how they affect vegetation that grows from soil. Instructor: Valerie Little, Judith Uhrick, and Judy Thrasher Ages: 9 & up Cost: $25 Max: 15
Forest Insect Camp June 20th 10:00 a.m. – 1:00 p.m. Location: Meet at 4-H office or Clemmons Educational State Forest - Picnic Shelter Do you like to walk in the woods? Do you like to turn over logs and see what lives under them? Come learn about the insects that live in our forests and streams. We'll walk the trails at Clemmons and visit streams to catch insects. You will learn how to identify them and different ways to catch them. Then you will learn about insect anatomy by dissecting a grasshopper. Bring sunscreen, drinks, and snacks. Closed toe shoes only. Transportation available. If riding from the 4-H Office, we will leave at 9:15 and return by 1:30p.m. Instructors: Dr. Kelly Oten and Grayson Barefoot Ages: 12 & up Cost: $15 Max: 12
College Tours
June 21st - June 23rd Location: Meet at 4-H Office
The following College Tours are scheduled for this summer. We will have an information session and tour of the campuses. Dress casual, but in compliance with the 4-H Code of Conduct. Wear comfortable walking shoes, apply sunscreen or bring it with you. Please bring your lunch, drinks and any snacks you will want for the day. Please note time differences of each College Day.
June 21st – Bulldogs and Pirates / 8:30 a.m. – 4:30 p.m. June 22nd – NCSU & Pacers / 8 a.m. – 5 p.m. June 23rd – Mount Olive & UNCW / 8 a.m. – 5 p.m.
Instructor: Lori McBryde
Ages: 9th grade & up Cost: $10 Max: 12
Theater and Books in the Summer!
June 21st & June 22nd (4th & 5th graders) 9:00a.m. - 1:00p.m. Location: 4-H Office June 22nd (Rising 1st-5th graders)
Read and discuss familiar tales while helping bring them to life on stage! This is a 2-day camp for rising 1st – 5th Graders.
The 4th and 5th graders will come on June 21st to prepare and practice their reenactment of a popular children’s story. They will also create the props and costumes for their play.
The rising 1st – 3rd graders will come on June 22nd to watch the play the older children will perform for them. After watching the play, they will read the tale and do some fun activities that go along with the book. As time allows, all children will have fun reading together. All participants will receive books for attending the camp. Bring your own snack and drink. ** Rising 4th and 5th graders will come both days. Instructor: Josh Chamblee Golden Leaf Scholar
Ages: Rising 1st – 5th graders Cost: $10 Max: 20
Islands, Boats, and Beaches!
June 26th 1:00 p.m. – 4:00 p.m. Location: Livestock Arena
Have fun making sailboats to float in the tub or pool, tropical islands in a jar to display, and delicious edible islands to eat. Instructor: Angie Schexnayder
Ages: 8 -12 Cost: $15 Max: 20
Ooey Gooey Bubbly Ooze!
June 26th and 27th 9:00 a.m. – 12:00 Noon Location: Livestock Arena
Young scientists will enjoy making bubble bombs, dancing raisins, bubble juice, and more!
In this three-day series, participants will make a machine quilted lap blanket to take home. Please be aware of the following prior to signing up:
1. Participants must have sewing machine experience, no exceptions!2. Participants will need to be here ALL three days to complete the project.3. All materials will be provided.4. Wear closed toed shoes.5. Bring your lunch, snacks, and drinks.
Instructors: Jo Co Quilters Ages: Must have sewing machine experience Cost: $25.00 Max: 6
Learn to hand quilt an adorable princess wall hanging. Instructor: Angie Schexnayder
Ages: 8-12 Cost: $15 Max: 15
Patriotic Crafts
June 28th 9:00 a.m. – 12 Noon Location: Livestock Arena
Prepare to celebrate our nation’s birthday with fun patriotic crafts. We will paint tee shirts and canvas as well as other patriotic crafts. Bring a white tee shirt to paint. All other materials will be provided. Instructor: Angie Schexnayder
Ages: 6- 9 Cost: $15 Max: 20
Rings, Wings, and Other Flying Things!
June 29th 9:00 a.m. – 12 Noon Location: 4-H Office
We will make spinning blimps, roto-copters, hoopsters, and more. Get airborne with the hoopster or fabulous foam flyer. Instructor: Angie Schexnayder
Learn how to make colonial dolls! We will hand sew colonial dolls. We will embellish by adding hair, embroidered faces, and clothes. Instructor: Angie Schexnayder
Ages: 8-12 Cost: $15 Max: 15
Colonial Cooking
June 30th 9:00 a.m.-12 Noon Location: 4-H Office
Enjoy a day from the past! We will make and bake Johnny Cakes and homemade butter. While our cake bakes, we will make frontier caps, pioneer bonnets, and edible log cabins. Instructor: Angie Schexnayder
Ages: 6-10 Cost: $13 Max: 15
Holiday Felting Fun!
July 6th 9:00 a.m.- 12:00 Noon Location: 4-H Office
Make a needle felted craft that could be made into an ornament, pin, or decoration. Campers will learn about cleaning and carding wool. Much of the wool campers make their take-home crafts from, will be wool from a local farm.
Instructor: Cecilia Fricke and 4-H Friends 4-H Club
Ages: 7-13 Cost: $15 Max: 10
Betsy Jeff Penn 4-H Camp July 9th – 14th Location: Reidsville, NC
ONLY ONE GIRL SPOT LEFT
Youth enjoy swimming, canoeing, ropes course, archery, craft, environmental science studies, as well as other fun-filled activities. The older groups participate in team building and an overnight off site camp out. Evening Programs consist of talent show, land/water sports, campfires, award ceremony, and dance.
This fee includes transportation, lodging and meals at camp, insurance, activities, T-Shirt, and $15 on Camp Store Card. Additional money will be needed for lunch on Sunday and Friday.
Ages: 8-14 Cost: 8-12 yrs. $220/13-14 yrs. $240
Messy Messy Mystery Mixtures
July 10th & 11th 9:00 a.m.-12 Noon Location: Livestock Arena
Get messy with exploragoo and outrageous ooze! Lots of fun mixes and messes!
This camp was designed specifically for boys but girls will enjoy it also! We will hand applique a cute dog. You will have a fun time sewing these wall hangings!
Instructor: Angie Schexnayder
Ages: 8-12 Cost: $15 Max: 15
Rice Pads
July 12th 9:00 a.m. - 12 Noon Location: 4-H Office Learn to use the sewing machine to make a rice pad. Dried lavender flowers can be added to the rice pads before sewing them closed for added soothing scents. No sewing experience is necessary. All levels of experience are welcome!! Instructor: Angie Schexnayder Ages: 8-12 Cost: $15 Max: 10
Envelope Bags
July 12th 1:00 p.m. - 4:00 p.m. Location: 4-H Office We will make envelope bags perfect for keeping special treasures, change, Kleenex, toys, etc. Several may be made as time allows. All levels of experience welcome! Instructor: Angie Schexnayder Ages: 8-12 Cost: $13 Max: 10
Super Hero/ Princess Party
July 13th 9:00 a.m.- 12:00 Noon Location: 4-H Office Let’s party!!! We will make special capes perfect for superheroes and princesses. We will play games and decorate cookies to enjoy during our party. Instructor: Angie Schexnayder Ages: 5-9 Cost: $17 Max: 20
Fairy Gardens
July 13th 1:00 p.m.- 4:00 p.m. Location: 4-H Office We will make miniature gardens perfect for fairies. Each participant will design and decorate their fairy homes. Instructor: Angie Schexnayder Ages: 6-10 Cost: $20 Max: 20
Tea Party
July 14th 9:00 a.m.- 12:00 Noon Location: 4-H Office We will enjoy tasting different teas, decorating gingerbread cookies and making some yummy snacks! We will also play tea party games and make fun tea party crafts. Come dressed up or you can make things to accessorize and dress you up for your tea party. A fun time will be had by all. Instructor: Angie Schexnayder Ages: 5-9 Cost: $17 Max: 20
Yo Yo Sachets and Headbands
July 14th 1:00 p.m. - 4:00 p.m. Location: 4-H Office
These sachets are adorable and perfect for displaying at home or sharing with someone. Participants will learn to make yo yos by hand and machine sew sachets. We will also make beautiful headbands. All levels of sewing experience welcome. Instructor: Angie Schexnayder
Ages: 8-12 Cost: $13 Max: 10
Living Life Healthy
July 17th – 19th 8:30 a.m. - 4:30 p.m. Location: Meet at 4-H Office
Come join us as we take a few days to see how much fun and tasty it can be living healthy. We will discuss things in the following topic areas: Chefs in the Kitchen, Community Gardens, Health Rocks, Stress Management, Exercise, Bullying and Self-esteem. Instructor: Lori McBryde
Ages: 3rd – 5th grades Cost: $20 Max: 16
Jewelry Crafting
July 18th 9:00 a.m. – 3:00 p.m. Location: Livestock Arena
Come enjoy a creative workshop that will have you crimping, beading, wiring and more as you create one of a kind masterpiece by using beads and wire. Participants will learn to color coordinate, string beads, make wire findings and learn jewelry making skills while designing several new creations of your very own to wear, to share, or embellish! Instructor: Teresa Byrd
Ages: 12 & Over Cost: $20 Max: 12
Just Horsin' Around
July 20th 9:00 a.m. – 3:00 p.m. Location: Creekside Equestrian Center 3905 Swift Creek Rd Smithfield, NC 27577
Would you like to know what it's like to care for and even ride a horse? Have you always wanted a horse but just didn't have a place to keep an animal? Then this one-day camp is for you. Come learn about different breeds of horses and the equipment required for ownership. Learn how to saddle, feed, and groom a horse. You can even make horse themed crafts. There will be lots of horseback riding both in the arena and on out on the trails.This camp is a fundraiser for the Jessica Ferrara Equine Memorial Endowment, which will benefit horse club members in Johnston County. Bring a lunch, snacks and plenty of drink to stay hydrated. **** Please wear closed toed shoes and sunscreen
Instructors: Leaders & Members of Creekside Dream Hunters & Jo Co Rockin Riders 4-H
Ages: 8 & Up Cost: $30 Max: 30
Get a Bang out of 4-H with Target Sports Camp July 20th 9:00 a.m. – 3:00 p.m. Location: H2O Fowl Farms
3494 Fairground Rd Dunn, NC 28334
Students will learn to shoot Trap, 3-D Recurve Archery, Competition Muzzle Loading, and Competition 3-Position .22 Rifle from Certified Instructors. Parents will be required to sign Liability Release Forms for students to participate. All equipment and ammunition will be provided. Please bring lunch, snacks, and drinks. Wear closed toe shoes and apply sunscreen. Instructors: Johnston County 4-H Target Sports Club Leaders Ages: 9-18 Cost: $30 Max: 24 Same camp as July 21st
Get a Bang out of 4-H with Target Sports Camp July 21st 9:00 a.m. – 3:00 p.m. Location: H2O Fowl Farms
3494 Fairground Rd Dunn, NC 28334
Students will learn to shoot Trap, 3-D Recurve Archery, Competition Muzzle Loading, and Competition 3-Position .22 Rifle from Certified Instructors. Parents will be required to sign Liability Release Forms for students to participate. All equipment and ammunition will be provided. Please bring lunch, snacks, and drinks. Wear closed toe shoes and apply sunscreen. Instructors: Johnston County 4-H Target Sports Club Leaders Ages: 9-18 Cost: $30 Max: 24 Same camp as July 20th
Spend a Day at the Dairy!
July 25th 7:30a.m. - 1:00p.m. Location: Meet at 4-H Office Would you like to visit a working dairy farm and enjoy some delicious ice cream? The join us for an exciting and educational tour of Simply Natural Creamery and Jersey Farm. We will go on a hay ride, tour the milking and cow lounging barn, view the milk processing and packaging room, milk a simulated cow and sample some free ice cream. We will eat lunch on site at their picnic and play area so bring a bag lunch and drink. If you want to purchase additional ice cream, bring money for that. Instructor: Lori McBryde Ages: 8 - 12 Cost: $13 Max: 12
North Carolina 4-H Congress
July 29th – August 1st Location: NCSU & Jane S. McKimmon Center Raleigh, NC
Teens from all over North Carolina will be coming together to participate in a leadership and citizenship activities. This is even an excellent way to develop and exercise leadership skills through serving on committees and participating on the Community Service Opportunities throughout the four days. In addition, youth will have great food, fun and lots of dancing.
New State 4-H Officers will also be elected, so join us learning more about the political process, how to become a 4-H Ambassador, who your fellow 4-H'ers are from across the state and how much fun 4-H really can be. Lodging will be on NCSU Campus at University Towers. Registration Deadline is June 12th, and payment must accompany registration. Ages: 13 –18 Cost: Around $270 Max: 12
Assist Girls in 3rd World Countries
August 7th 9:00 a.m. - 4:00 p.m. Location: Livestock Arena
Do you realize how easy we have life here in America? Would you like to help improve the quality of life for those with little resources? You can do this without leaving Johnston County! You will be making personal hygiene products for school aged girls in 3rd world countries. By making these items we can help increase their school attendance. You will also have the opportunity to make an elastic waisted skirt for yourself! Some sewing experience is preferred but not required. Instructor: Teresa Byrd
Ages: 12 & up Cost: $10 Max: 10
Assist Boys in 3rd World Countries
August 9th 9:00 a.m.- 12:00 Noon Location: 4-H Office
Do you realize how easy we have life here in America? Would you like to help improve the quality of life for those with little resources? You can do this without leaving Johnston County! You will be making pocket fishing kits for school aged boys in 3rd world countries. You will also have the opportunity to make a PVC pocket fishing kit for yourself! Instructor: Teresa Byrd
Ages: 12 & up Cost: $10 Max: 10
For accommodations for persons with disabilities, contact Bryant Spivey at 919-989-5380, no later than five business days before the event.
JOHNSTON COUNTY 4-H 2017 SUMMER FUN REGISTRATIONThis form MUST accompany registration and payment by June 1st .
4-H Club: ______________________________ Participated in 2016 Summer Fun? Yes No
There will be a sign-in and sign-out procedure that everyone must follow for safety!
Date Time Activity Cost Check Class
Clover Cash Amt
Money Rec’d
Trans. Needed
Y/N
June 12 9:00-12:00 Animal Tracks @Howell Woods $20.00
June 14 9:00-12:00 Geocaching @Howell Woods $20.00
June 15 9:00-12:00 Fishing Frenzy @Howell Woods $20.00
June 19 1:00-5:30 Blue Devil’s Day $10.00 June 19,20,21,22,23
9:00-12:00 Jr. Master Gardner $25.00 N/A
June 20 10:00- 1:00 Forest Insect Camp $15.00
June 21 8:30-4:30 Bulldogs and Pirates Day $10.00 June 21,22 9:00-1:00
Theater and Books in the Summer! (4th-5th grade)
$10.00 N/A
June 22 9:00-1:00
Theater and Books in the Summer! (1st, 2nd, 3rd grade)
$10.00 N/A
June 22 8:00-5:00 Wolfpack or Pacer $10.00
June 23 8:00-5:00 Mount Olive and UNCW $10.00
June 26 1:00-4:00 Islands, Boats, and Beaches! $15.00 N/A
June 26,27 9:00-12:00 Ooey Gooey Bubbly Ooze! $20.00 N/A
June 26,27,28 10:00-3:00 Stitch by Stitch Quilting $15.00 N/A
June 27,28 1:00-4:00 Princess Wall Hanging $12.00 N/A
June 28 9:00-12:00 Patriotic Crafts $15.00 N/A
June 29 9:00-12:00 Rings, Wings, and other Flying Things! $17.00 N/A
June 29,30 1:00-4:00 Folk Dolls $15.00 N/A
June 30 9:00-12:00 Colonial Cooking $13.00 N/A
July 6 9:00-12:00 Holiday Felting Fun! $15.00 N/A
July 9-14 All Week Betsy –Jeff Penn Camp (only 1 girl spot left) $220/ $240
July 10,11 9:00-12:00 Messy, Messy Mystery Mixtures $20.00 N/A
July 10,11 1:00-4:00 Adorable Dog Applique $15.00 N/A
July 12 9:00-12:00 Rice Pads $15.00 N/A
July 12 1:00-4:00 Envelope Bags $13.00 N/A
July 13 9:00-12:00 Super Hero/ Princess Party $17.00 N/A
July 13 1:00-4:00 Fairy Gardens $20.00 N/A
July 14 9:00-12:00 Tea Party $17.00 N/A
July 14 1:00-4:00 YoYo Sachets and Headbands $13.00 N/A
July 17,18,19 8:30-4:30 Living Life Healthy $20.00 N/A
July 18 9:00-3:00 Jewelry Crafting $20.00 N/A
July 20 9:00-3:00 Just Horsin’ Around $30.00 N/A
July 20 9:00-3:00 Get a Bang Out of 4-H $30.00 N/A
July 21 9:00-3:00 Get a Bang Out of 4-H $30.00 N/A
July 25 7:30-1:00 Spend a Day at the Dairy $13.00 July 29- Aug 1
Sat, Sun, Mon, Tues
4-H Congress Around$270
August 7 9:00-4:00 Service Project to Assist Girls in 3rd World Counties $10.00
N/A
August 9 9:00-12:00 Service Project to Assist Boys in 3rd World Counties $10.00 N/A
OFFICE USE ONLY! Balance Due _______ minus Clover Cash _______ = Amount to Pay __________
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4-H Enrollment Form
Name of 4-H Group/Unit:______________________________________________ Year :_____________ Member Name: _____________________________________________________________________________ First Middle Last
Address:____________________________________________________________________________________ Street Address City State Zip Code
Phone:(____) __________________ Email: ______________________________ County:_________________ Gender* : Male Female Date of Bir th:____________ Grade: ________ School Attending:__________________
I f re-enrolling in 4-H, how many years have you been in 4-H: ______ Do you live* : Farm City over 50,000 people (Choose only one) Town under 10,000 people or rural non-farm Suburbs of city over 50,000 people City 10,000-50,000 people Military installation: ______________________ Do you have parent/guardian(s) active in the military? Yes___ No____ I f yes, circle all that apply: Army Air Force Navy Marines Coast Guard National Guard(Air & Army) Reserves Ethnic group:* A. Choose One: Hispanic or Latino Non-Hispanic or Latino B. Choose all that apply: White or Caucasian Asian Black or African-American Native Hawaiian or other Pacific Islander American Indian or Alaska Native Other ____________________
Parent or Guardian: _____________________________________________________________________________ First Middle Last
Address: _______________________________________________________________________________________ Street Address City State Zip Code
Phone: ____________________ ( _____) ______________________ ( _____) ___________________________ Area Code Daytime/Cell phone Area Code Home phone Email (if applicable)
Additional Parent or Guardian: ____________________________________________________________________ First Middle Last
Address: _______________________________________________________________________________________ Street Address City State Zip Code
Phone: ____________________ ( _____) ______________________ ( _____) ___________________________ Area Code Daytime/Cell phone Area Code Home phone Email (if applicable) 1. A parent or guardian should sign below whichever statements you wish to apply to the youth’s involvement in 4-H programs.
_______________________________________ I agree to allow 4-H to take photographs/audio/video of my child for use in 4-H and other N.C. Cooperative Extension educational, promotional, and/or marketing materials. Neither individual addresses nor telephone numbers will be published within these materials. _______________________________________ I do not wish for 4-H to take photographs/audio/video of my child for use in 4-H or N.C. Cooperative Extension educational, promotional or marketing purposes. 2. The enrolling youth is bound by the NC 4-H Code of Conduct and Disciplinary Procedure for 4-H events and activities. The youth should initial here if he/she has received and reviewed the NC 4-H Code of Conduct and Disciplinary Procedure for 4-H events and activities: ___________. *This information is required for all federally assisted programs and is solely used for the purpose of determining compliance with Federal civil rights laws; your responses will not affect consideration of your application. By providing this information, you will assist us in assuring that this program is administered in a nondiscriminatory manner.
Revised 10/21/13
Distributed in furtherance of the acts of Congress of May 8 and June 30, 1914. North Carolina State University and North Carolina A&T State University commit themselves to positive action to secure equal opportunity regardless of race, color, creed, national origin, religion, sex, age, or disability. In addition, the two Universities welcome all persons without regard to sexual orientation. North Carolina State University, North Carolina A&T State University, U.S. Department of Agriculture, and local governments cooperating.
For office use only 4-H Membership #_______________
Date entered:_____________
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Must be completed each year by 4-H’er and Parent/Guardian. If health history changes within that year, it is the 4-H’er & Parent/Guardian’s responsibility for updating
information. Approved as of 3/02/06
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4-H MEDICAL INFORMATION AND INFORMED CONSENT FOR TREATMENT FOR NC 4-H SPONSORED EVENTS
PLEASE READ AND COMPLETE THE FOLLOWING FORM. THIS FORM MUST BE PRESENTED AT THE OFFICIAL REGISTRATION FOR THE 4-H SPONSORED EVENT BEING ATTENDED.
I. Medical Information
Known allergies to foods, drugs, insect stings or bites, etc: _________________________________________________
Special medical concerns or conditions that event supervisors should know about, including contagious illnesses, epilepsy, asthma, diabetes, previous injuries to bones/joints, etc.: _________________________________________________________________
List special dietary needs: ________________________________________________________________________
Medications currently being taken (name of medication, dose, and frequency):__________________________________________________
Family Physician: Name ___________________________________ Phone # (____) ____________
The 4-H program purchases insurance for youth participants for many sponsored events. In some cases, this coverage will not pay for some medical expenses and it may be necessary to bill the family or your insurance company.
Health Insurance Company ______________________________________________________________ Health Insurance Policy # _______________________________________________________________ Company Address ____________________________________________________________________________ Phone Company Telephone Number (____)___________________________________________
III.
If you are a person with a disability and desire any assistive devices, services or other accommodations to participate in this activity, please contact __________ [name, office] at __________ [phone number/TTY] during business hours of 8 a.m. and 5 p.m. to discuss accommodations at least __________ [hours/days] prior to the activity.
Parent/Guardian telephone #: Home _______________________ Work ________________________
Must be completed each year by 4-H’er and Parent/Guardian. If health history changes within that year, it is the 4-H’er & Parent/Guardian’s responsibility for updating
information. Approved as of 3/02/06
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IV. Informed Consent In the event that a participant needs minor medical care from 4-H or more significant medical care from a qualified heal care provider, including in rare cases possible hospitalization and/or surgery, the parent/guardian is asked to sign the informed consent form below. In case of serious medical condition, 4-H will make every effort to notify the parents, but the first priority may be providing care to the participant. Authorization to Consent to Health Care for Minor I, _______________________________________, of ________________________ County, am the custodial parent having legal custody of __________________________, a minor child, age ________, born _____________________________. I authorize any adult(s) acting as agents (including official volunteers) or employees of the ________________________ 4-H program and in whose care the minor child has been entrusted , to do any acts which may be necessary or proper to provide for the health care of the minor child, including , but not limited to, the power (i) to provide for such health care at any hospital or other institution, or the employing of any physician, dentist, nurse, or other person for such health care, and (ii) to consent to and authorize any health care, including administration of anesthesia, X-ray examination, performance of operations, and other procedures by physicians, dentists, and other medical personnel except the withholding or withdrawal of life sustaining procedures. This consent shall be effective for one year from the date of the execution. Custodial Parent Signature_______________________________________Date_______ STATE OF NORTH CAROLINA COUNTY OF _________________________ On this _________ day of ________________, 20___, personally appeared before me the said named, _____________________________, to me known and known to me to be the person described in and who executed the foregoing instrument and he (or she) acknowledged that he (or she) executed the same and being duly sworn by me, made oath that the statements in the foregoing instrument are true. My commission expires ________________________________________, 20_____. Notary Public (OFFICIAL SEAL)
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4-H Code of Conduct and Disciplinary Procedure North Carolina Cooperative Extension Service
Department of 4-H Youth Development I. Purpose and Application:
A. The 4-H Code of Conduct is intended to foster a safe environment that is conducive to optimal learning and growth. Toward that end, youth participants are expected to behave in a way that respects the rights and property of others, and that will not disrupt or interfere with 4-H program goals.
B. This 4-H Code of Conduct and Disciplinary Procedure is a condition of participation in any North Carolina 4-H activities or programs.
II. Behaviors Prohibited at 4-H program Activities:
A. Possession, selling, and/or use of alcoholic beverages, tobacco products, and illegal drugs OR being present where individuals are using alcohol, tobacco products and/or any illegal substances
B. Any kind of sexually related physical contact C. Possession of weapons or firearms (except while participating in a 4-H
Shooting Sports Event) D. Behavior that violates state or local laws E. Damage to property of others F. Theft, misuse or abuse of public or personal property G. Conduct that jeopardizes the safety of self or others H. Conduct that disrupts or interferes with 4-H programming I. Leaving a program or facility without permission of parents or 4-H staff
(including authorized volunteers) J. Inappropriate dress, including but not limited to clothing that is sexually
suggestive, indecent, or otherwise disruptive to the operations or goals of 4-H. Examples include clothing with negative or hateful language or symbols; see-through blouses, skirts or pants; sagging pants; exposed undergarments; bare midriff shirts; and excessively short or tight garments. Clothing should meet the standards expected in public schools. Specific clothing requirements may be required where appropriate for a particular event
K. Unruly behavior in hotels and public areas, particularly during overnight events. There should be no running in the halls, prank calls, unnecessary noise, excessively late hours, or visiting in rooms of the opposite sex
III. Additional Basis for Disciplinary Action
County or State Extension personnel may impose discipline pursuant to Part IV below in cases of misconduct by current, former, or prospective 4-H participants if, in the judgment of 4-H personnel or their supervisors, the misconduct poses a potential risk to the 4-H program. This includes risks to the safety or well-being of others and risks to the effective functioning or integrity of 4-H. This applies regardless of whether the misconduct occurred during a 4-H activity or in a setting unrelated to 4-H activity.
Approved of 3/26/10 2 of 2
IV. Disciplinary Procedures:
A. Discipline may be imposed by any 4-H staff or Cooperative Extension Service employee who has oversight responsibility for 4-H activities.
B. Unless immediate action is required, the following procedures must take place before there can be any finding or conclusion of guilt: 1) the accused participant shall be told the charge (which of the prohibited
behaviors listed above he or she is accused of violating), and 2) the accused participant is told what factual evidence supports the charge,
and 3) the accused participant has been given a chance to tell his/her side of the
story. C. The 4-H staff person must be satisfied that the participant more likely than not
engaged in the prohibited behavior before imposing a sanction. D. Sanctions may include some or all of the following:
1) Verbal warning 2) Notification to parents 3) Immediate removal from the activity 4) Being placed on a behavior contract 5) Referral to local law enforcement and/or juvenile court 6) Program suspension and/or 7) Expulsion from program 8) Other sanctions appropriate to the circumstances, as determined by 4-H.
E. Appeals 1) Disciplinary action for local or county-level events may be appealed to the County Director and or 4-H Agent. All appeals must in writing and must be received by the County Director and or 4-H Agent within 30 days of the disciplinary action. The County Director and or 4-H Agent or designee shall review the appeal statement, any written response from the decision maker, and may review other relevant information. The County Director and or 4-H Agent shall send a written decision to the appellant, the 4-H staff member who made the initial decision, and Head of the Department of 4-H Youth Development. The County Director and or 4-H Agent’s appeal decision shall constitute the final agency action unless the Department Head chooses to exercise further review.
2) Disciplinary action for regional or state-level events may be appealed to the Head of the Department of 4-H Youth Development, Cooperative Extension Service, Box 7606, NC State University, Raleigh NC 27695-7606; telephone (919) 515-3242. All appeals must in writing and must be received by the Department within 30 days of the disciplinary action. The Department Head or designee shall review the appeal statement, any written response from the decision maker, and may review other relevant information. The Department Head shall send a written decision to the appellant and the 4-H staff member who made the initial decision, and the Department Head’s appeal decision shall constitute the final agency action.
F. Immediate action situations: 4-H or Extension staff may take immediate action to remove a participant from an activity and other action as needed, where there is an emergency situation or significant risk of continuing misconduct. In those cases, the immediate action is temporary discipline and the 4-H or Extension staff must arrange for the procedures in parts B, C, D, and E above as soon as possible but in no event longer than seven days from the temporary discipline.
