20142014 Iowa State University Extension and OutreachIowa State University Extension and Outreach——Emmet CountyEmmet County

Summer Day CampsSummer Day Camps

FUNFUNFUN

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New FriendsNew FriendsNew Friends

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JuneJuneJune ThroughThroughThrough AugustAugustAugust

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SSSUUUMMMMMMEEER R R CCCAAAMMMPPPSSS 20142014

SUPER SUMMER FUN CAMP

☼ Thursday, June 5th, 8:30-4:30

☼ Completed Grades K-1st

☼ Emmet County Fairgrounds

☼ Have fun playing crazy games, making cool crafts, doing wacky experiments, learning sun safety, swimming at RWC, & more!

Summer Celebration Camp

☼ Thursday, June 12th, 8:30-4:30

☼ Completed Grades 4th-6th

☼ Emmet County Fairgrounds

☼ A busy day of awesome crafts, water games, summer safety, cool experiments, ice cream sundaes, swimming at RWC, plus surprises!

Fun In The Sun Camp

☼ Thursday, June 19th, 8:30-4:30

☼ Completed Grades 2nd-3rd

☼ Emmet County Fairgrounds

☼ Expect a day of excitement and fun with games, crafts, activities, experiments, water relays, swimming at RWC, & even more!

Havin’ A Blast in the USA

☼ Thursday, July 3rd, 8:30-4:30

☼ Completed Grades 3rd-6th

☼ Emmet County Fairgrounds

☼ Join our 4th of July party with everything Red, White, & Blue! Rockets, crafts, games, delicious snacks, and lots more party fun!

Havin’ A Ball Camp

☼ Thursday, July 10th, 8:30-4:30

☼ Completed Grades K-2nd

☼ Emmet County Fairgrounds

☼ Enjoy activities, crafts, games, snacks, challenges, and experiments all about balls & sports! Also, bowling and gym time at the RWC!

Sports Spectacular Camp

☼ Thursday, August 14th, 8:30-4:30

☼ Completed Grades 3rd-6th

☼ Emmet County Fairgrounds

☼ It will be a day of sports related activities, crafts, experiments, games, and more….plus bowling and gym time at the RWC!

The fees for service will be used to off-set direct expenses and to support the 4-H Youth Development County Extension Program. Iowa State University Extension and Outreach programs are available to all without regard to race, color, age, religion, national origin, sexual orientation, gender identity, genetic information, sex,

marital status, disability, or status as a U.S. veteran.

Special thanks to the

Emmet County

Community Foundation

for financial support of

these camps!

2014 ISU Extension Summer Day Camp Registration Form2014 ISU Extension Summer Day Camp Registration Form2014 ISU Extension Summer Day Camp Registration Form DUE BY May 23DUE BY May 23DUE BY May 23

It’s easy to register! Registrations are processed in order received at the Emmet County Extension Office. Enrollment maximum is 40 kids per camp. Complete this form for EACH camper. Copy as needed. Please legibly

print all information on both sides. Contact Marcy Sander with questions at (712) 362-3434 or mlsander@iastate.edu. Send or bring in your registration form (cut this sheet off) and fees to:

The Emmet County Extension Office, 26 S. 17 St., Estherville, IA 51334

1.1. CCAMPERAMPER IINFONFO

Name Last First

Date of birth Age at camp Grade Completed (spring 2014) Gender

Home Address

City State Zip School

2.2. PPARENTARENT/G/GUARDIANUARDIAN IINFONFO

Family email address

Mother/Guardian #1 name

Home phone Work phone Cell Phone

Father/Guardian #2 name

Home phone Work phone Cell Phone

3. DDAYAY CCAMPAMP CHOICESCHOICES

Camp Name Location Date Grades Fee

Super Summer Fun Camp Fairgrounds June 5 K-1 $20.00

Summer Celebration Camp Fairgrounds June 12 4-6 $20.00

Fun In The Sun Camp Fairgrounds June 19 2-3 $20.00

Havin’ A Blast in the USA Camp Fairgrounds July 3 3-6 $20.00

Havin’ A Ball Camp Fairgrounds July 10 K-2 $20.00

Sports Spectacular Camp Fairgrounds August 14 3-6 $20.00

TOTAL NUMBER OF CAMPS= FEES DUE=

Emmet County 4-H Members and 2014 Clover Kids Members subtract $5 per camp registered for: (- )

TOTAL FEES DUE: $ Please make checks payable to: Emmet County Extension

$

Space is

limited,

Sign up early!

INSURANCE POLICY INFORMATIONINSURANCE POLICY INFORMATION The above-named participant is covered by health insurance. Yes** No* * If no, initial this line stating that you do not have health insurance and are aware that Iowa State University/University Extension/4-H does not carry any health insurance for you. ** If yes, provide the following information which is required by Iowa State University to expedite treatment and to facilitate the billing process.

Policy Holder’s (P.H.) Name P.H.’s Date of Birth

Address Relation to Participant

City, State, Zip Occupation

P.H.’s Employer’s Name/Address

Insurance Company Name

Policy # Plan #

MEDICAL EMERGENCY CONTACT INFORMATIONMEDICAL EMERGENCY CONTACT INFORMATION

Person to Contact First Backup Contact (Relative or Friend)

Name Name

Relation to Participant Relation to Participant

Daytime Phone Daytime Phone

Cell Phone Cell Phone

Name of Family Doctor Doctor Phone Number

Name of Dentist Dentist Phone Number

HEALTH INFORMATIONHEALTH INFORMATION Does the child have any of the following conditions or a history of any of the following conditions? (Check all that apply.) Asthma Bronchitis Fainting Spells Diabetes Ear Infections Heart or cardio-vascular problems/disease Convulsions/seizure Hay Fever Chronic bone, muscle or joint injuries Migraine headaches Other condition(s): (Please list)_____________________________________________________ In order for us to be sure to have enough staff to meet the needs of each child, please notify us if your child is on an IEP at school or if they have any special needs: Allergies or reactions: (Check all that apply.) Aspirin Penicillin Dairy Gluten Peanuts Insect bites or stings Ivy/oak/sumac toxins Other (list) _________________________ Is your child currently on any prescribed or over-the counter medication? (If so, please record the condition/ailment, name of medication, dosage, time(s) of day, prescribing physician.) **If medication needs to be given while at camp, please ask staff for a medication form to complete.

___________________________________________________________________________________________________________________

Date of last tetanus shot (approximate if necessary):_________________________________

TO BE READ AND SIGNED BY PARTICIPANTTO BE READ AND SIGNED BY PARTICIPANT——BEHAVIOR EXPECTATIONS OF THE PARTICIPANTBEHAVIOR EXPECTATIONS OF THE PARTICIPANT It is important to follow the directions of the camp leader(s) at all times. I understand that as a participant I have the responsibility to help make the activity a safe experience for everyone through my behavior and conduct. I also understand the danger of not following rules and directions and agree to follow them.

Participant (camper) Signature: Date

TO BE READ AND SIGNED BY PARENT OR GUARDIANTO BE READ AND SIGNED BY PARENT OR GUARDIAN I understand that my child must be healthy and reasonably fit in order to safely participate in camp recreation activities and that I will inform the program leader(s) of any medication, ailment, condition, or injury that may affect his/her ability to participate safely.

MEDICAL EMERGENCY PARENTAL PERMISSION* The health history for my child is correct and complete to my knowledge. If an injury or other medical condition occurs or arises, I hereby give permission to the ISU Extension staff or volunteer to provide routine health care and seek emergency treatment including x-rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing or insurance purposes. I understand that I am financially responsible for charges and hereby guarantee full payment to the attending physicians or health care unit. In the event of an emergency where I cannot decide for my child, I give permission to the physician/hospital selected by the ISU Extension staff or volunteer to secure and administer treatment for my child, including hospitalization. (*If you cannot sign this section of the form for any reason, contact the County Extension Staff regarding a legal waiver in order to attend and participate.)

_________initial __________date

PUBLICITY/IMAGE/VOICE PERMISSION The Iowa State University Extension Program normally takes photographs, video, and/or tape recording of our programs. During activities, a photograph or video/audio recording may be taken of you or your child. Unless you request otherwise, your initial below will be considered permission for Iowa State University and the day camp program to photograph, film, audio/video tape, record and/or televise your image and/or voice or the image and/or voice of your child for use in any publications or promotional materials, in any medium now known or developed in the future without any restrictions. If you object to ISU using you or your child’s image or voice in this manner, please notify the program leader.

_________initial __________date

ASSUMPTION OF RISK AND RELEASE OF LIABILITY (Please read carefully)

I give permission for my child, (write child’s name on this line), to participate in the ISU Extension Day Camp program. I understand that camp activities/events may involve certain risks of physical activity and possible injury and that Iowa State University and its camp program will provide each participant with reasonable care, but that ISU cannot guarantee that my child will remain free of injury. In addition, some camp activities including but not limited to: water activities and other sporting activities have a higher degree of risk. I nonetheless wish to have my child participate as a camper in the ISU Extension Day Camp program and ASSUME the RISK of participating. I agree to RELEASE from LIABILITY, INDEMNIFY and HOLD HARMLESS the State of Iowa, the Board of Regents of the State of Iowa, ISU and ISU Extension and their officers, employees and agents (hereinafter the RELEASEES) from any and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my child’s participation in the camp program. This release, however, is not intended to release the above-mentioned RELEASEES from liability arising out of their sole negligence.

Parent or Guardian Signature Date