North Carolina Cooperative
Extension Service
Halifax County Center
Phone # (252)583-5161
Fax # (252)583-1683

4-H Rural Life Center
P.O. Box 37, Halifax, NC 27839
Located at 13763 Highway 903 in Halifax, NC

Phone # (252) 583-1821
www.halifaxnc.com/4hrurallife

IMPORTANT INFORMATION
Parent's signature is required on application

Camper’s Name: _____________________________________________

Age_____Grade_______Sex ______ Birthday __________________

Address:__________________________________________________

_________________________________________________________

Phone #:__________________________________________________

Camp Name(s) ____________________________________________

Date of Camp(s)____________________________________________

Camp #(s)_________________________________________________

If Bus transportation is provided, my child knows to ride the bus home on the following days:

Please Circle: Monday Tuesday Wednesday Friday

Bus does not run on Thursday afternoons.

(Please send us a written note if any of this needs to be changed.)
Please list names of responsible adults who can pick up your child/children at the end of the day, when camp is over.
Photo ID will be required for camper release.

_________________________________________________________

_________________________________________________________

_________________________________________________________

HALIFAX COUNTY AGREEMENT
FOR 4-H RURAL LIFE CENTER EVENTS

This release is entered on the date hereinafter mentioned by and between Halifax County 4-H and the parties, their names described hereinafter:

Whereas, the Halifax County 4-H Code of Conduct prohibits the following activities:

- Possession and/or use of alcoholic beverages and illegal drugs OR being present where individuals are partaking of alcohol and/or any illegal substances, and...

- Possession of weapons or firearms, and behavior that violates state or local laws, and

Whereas, the attendance and punctuality of the participants in scheduled meetings during this event is considered mandatory by all participants and unauthorized absence from the premises of the event is prohibited, and

Whereas, the Halifax County 4-H Code of Conduct requires that all members respect the property of others and the facility in which this particular 4-H sponsored event is held, and

Whereas, the policy of the Department of 4-H Youth Development and Halifax County 4-H Code of Conduct has been read, expressly understood, and agreed to by the undersigned.

NOW THEREFORE, in sole consideration for the opportunity extended to the undersigned 4-H participant by Halifax County to participate in the event, the parties enter into this release and mutually agree to the following:

The undersigned for themselves, their heirs, executors, administrators, and successors assign individually, jointly, and severally do forever release and agree to save and hold harmless and indemnify Halifax County and its agencies, departments, officers, employees, and servants from any and all liability that may arise out of any action or failure to act by any party from the youth’s participation in the 4-H event.

We realize that these guidelines are not all inclusive and that the event supervisor(s) reserve the right to revise and extend these policies. In general, exercising good judgment will prevent occurrences which are not within the best interests of participants or the 4-H event.

We Praise and use positive reinforcement as effective methods of the behavior management of children. When children receive positive, non-violent, and understanding interactions from adults and others, they develop good self-concepts, problem-solving abilities, and self-discipline.

When attending our program, your child is expected to:

1. Stay in the assigned areas
2. Stay with his assigned program leader
3. Use good manners at all times
4. Participate in all programmed activities
5. Be responsible for his behavior and language
6. OBEY ALL RULES AND REGULATIONS
7. Have FUN while LEARNING new skills
8. Use the TELEPHONE for authorized EMERGENCIES only

We, the undersigned, have carefully read the foregoing release, know the contents thereof, and sign it as our own free act. Any infraction of the above may necessitate the participants parent/guardian being notified and the event supervisor(s) determining an appropriate penalty which may include the participant being sent home at parents/guardian’s expense and/or suspended from future 4-H activities.


MEDICAL INFORMATION

On rare occasions, an emergency requiring hospitalization and/or surgery develops. As a general rule, anesthesia may not be administered to or operations performed upon a minor without written permission by his/her parents or guardians. Therefore, in order to prevent a dangerous delay, if an emergency does occur and we are unable to contact the parents or legal guardians, the parent/guardian is asked to sign the release form below.


Parent/Guardian_____________________________________________

Home phone _______________________________________________

Work phone________________________________________________

Home address________________________________________________

___________________________________________________________

Work address ______________________________________________

___________________________________________________________

Second Parent/Guardian/Emergency Contact______________________

_________________________________________________________

Phone ____________________________________________________



If neither parent or guardian can be contacted call:

Name_______________________________________________________

Relationship_______________________________________________

Phone__________



Health History: (Please check all that apply)
___ Sleepwalking ___Bedwetting ___Head Lice
___Heart Disorder ___Convulsions ___Tuberculosis
___Kidney Disorder ___Hepatitis ___Mental Disorder ___Other
Explain: ___________________________________________________
In the event of injury or illness to my son/daughter/ward, I authorize the 4-H representative to secure whatever treatment is deemed necessary and, if recommended by an attending physician, the administration of an anesthetic or surgery.

1. Known allergies to foods, drugs, insect stings, or bites, etc.: __________________________________________________________

2. Special medical or physical concerns or restrictions that event supervisors should know about, including epilepsy, asthma, diabetes, previous injuries, etc.: ___________________________________________________________
___________________________________________________________

3. Medications currently being taken, dose and frequency:  (Please turn all medications over to the camp health personnel while attending camp) ___________________________________________________________

4. Family Dentist___________________________________________
Address __________________________________________________
__________________________________________________________
Area Code and Phone Number______________________________________________

5. Family Physician ________________________________________
Address___________________________________________________

Area Code and Phone number _____________________________________________

Date of last tetanus shot (Attach Complete Shot Record)____________

6. It may be necessary to bill the family's insurance company. Please provide the following information:
Insurance Company _________________________________________
Insurance Policy #___________________________________________
Address___________________________________________________
_________________________________________________________
Area Code and Phone number_________________________________


PARENT’S AGREEMENT AND CONSENT FORM

1. PHOTOGRAPH RELEASE - I/we, the undersigned, hereby authorize the 4-H Camp to use photographs, which I/we have voluntarily allowed to be taken by representatives. I/we understand that such use may include, but shall not be limited to, publications, slide shows, displays, or videos. I /we hereby waive any right to which I/we or my/our heirs may otherwise be entitled by law to assert against the 4-H Camp on account of injury sustained by my/our reputation arising from causes of action including, but not limited to libel, slander, defamation of character and invasion of privacy as a result of such publications and hereby release the 4-H Camp from any liability on account of such injury.

2. FIELD TRIP PERMISSION
My child has permission to go on the field trip(s) planned as part of the summer 4-H Day Camp Program.

3. I AM RESPONSIBLE FOR:
- Picking up my child in the case he/she is ill or dismissed from camp.
- Being at the bus stop or camp or having someone there on time to pick up my child.
- Letting my child know whether or not to ride the bus.
- Terms of release of camper-proof of authorization to take custody of the child. (Photo ID)
- Medical cost and insurance - Neither the Halifax County 4-H Camp nor the camp staff shall be liable for the cost of any medical treatment.

4. CAMPER’S PERSONAL PROPERTY
Neither the 4-H Camp nor the camp staff shall be responsible for the loss of or damage to the personal property of the camper. Campers should not bring electronic devices or any other expensive items.

5. DAMAGE
Parents will be responsible for and pay for any damage done by my child either alone or with others.

6. NO ONE is to leave camp without the prior permission of the camp director.

7. MY CHILD has been examined by a licensed physician within the last twelve months and has been found to be physically fit and able to participate in all camp activities.

I/We have read and understand this entire form, front and back, and I/We agree to be bound by the conditions, releases, and agreements.

______________________________________________
Parent’s Signature

______________________________________________
Camper’s Signature

Date:_________________________________