The Georgia Junior Livestock Program “Youth learning through experience.”

May 7, 2015 TO: County Extension Agents and Agricultural Education Teachers FR: Jason Duggin Jacob Segars Christa Steinkamp

Beef Extension Specialist Beef Extension Specialist Georgia Agriculture Education (706/624-1403) (229/386-3214) (706/552-4460) jduggin@uga.edu jacobs@uga.edu csteinkamp@gaaged.org Examples of Life Skills Practiced: Leadership, Contribution to Group Effort, Teamwork, Self-motivation, Self-esteem, Self-responsibility, Managing Feelings, Self-Discipline, Personal Safety, Learning to Learn, Problem Solving, Goal Setting, Planning/Organizing, Keeping Records, Cooperation, Social Skills, Conflict Resolution, Accepting Differences, Sharing Main Character Pillars Practiced: Fairness and Responsibility We are extremely pleased to announce 2015 Georgia Beef School!

DATES: Monday, June 22 through Wednesday, June 24, 2015

WHO: Open to all youth -- 4-H and FFA

COST: $200 (includes 2 nights' lodging, all meals, instruction fees, t-shirt, plus board for animal) Registration Deadline: Registration forms are due to Christa Steinkamp 216 Four Towers, UGA, Athens, GA 30602 no later than June 1st. Fees are due at the time of submitting applications. Please make all checks payable to: North Region FFA. Beef School will be held at the Carroll County Ag Center, 900 Newnan Road, Carrollton, GA. We have excellent instructors and speakers lined up who will cover all the basics of owning, raising and showing a steer or heifer. Some of the topics include making beds, rinsing, hair care & washing; equipment care, what to take to a show, fitting and clipping, judging, showmanship, cattle selection, team events and graduation! Back by popular demand, Teen Leaders to Beef School! We are inviting any beef exhibitors who feel they know the basics, but still want to work on their fitting, clipping, showmanship skills and would like to work with Beef School participants, to apply as a Teen Leader. Teen Leaders will assist instructors and leaders in everyday activities but also have the opportunity to be involved with classes that will provide knowledge for all those at the beginning level to the most advanced. Teen Leaders who are selected to attend Beef School can register for $100 which includes all meals, lodging and registration fee. Teen Leaders are not allowed to bring a calf. Agents, teachers or other adults who wish to attend Beef School can register for $100 which includes all meals, lodging and registration fees. A limited number of agents and teachers may be asked to assist with Beef School and their fees may be paid by the school (depending on number of participants and budget availability.) Teachers / agents interested in serving as a leader at Beef School need to submit an Adult Leader application with payment for Beef School. Please be sure that both the student and calf is properly prepared to attend Beef School. In order to avoid safety issues with students and calves, calves should be completely halter trained for the students to handle on their own. We have experienced problems in the past with 4-H and FFA members bringing inappropriate calves to Beef School. Green broke calves and inexperienced students make a very dangerous combination. This may result in problems for the instructors, disruption in the classes and danger and headache for all involved.

The Georgia Junior Livestock Program “Youth learning through experience.”

All applications must be signed by the County Agent or Ag Ed Teacher involved. All participants and Teen Leaders must sign, and therefore agree, to abide by the Beef School Code of Conduct and the rules of Beef School. Please promote this activity in your county. We believe this school is just what we need to instill good ethics and sound management practices in the Youth Livestock Projects. Through excellent instruction we can empower these young people to properly care for and manage their own livestock. Thanks so much, in advance, for your support. Please let us know if we can answer any questions or be of assistance to you. cc: Kent Benson Keith Bertrand John Bridges Ben Lastly Jacob Segars Ronnie Silcox Arch Smith Heather Shultz Tommy Waldrop Ricky Wheeler

A Partnership Of The GA Dept. of Education’s FFA Program & The University of Georgia’s Animal & Dairy Science Dept. and 4-H Program

The University of Georgia and Fort Valley State University, the Georgia Department of Education, the U.S. Department of Agriculture, and counties of the state cooperating.

The Cooperative Extension Service offers educational programs, assistance and materials to all people without regard to race, color, national origin, age, sex or disability. An equal opportunity/affirmative action organization committed to a diverse work force.

4-H/FFA APPLICATION 2015 GEORGIA BEEF SCHOOL Carroll County Ag Center, 900 Newnan Road, Carrollton, GA

June 22-24, 2015

Applications due no later than June 1, 2015. Must be signed by County Extension Agent or Agriculture Education Teacher.

$200 Fee’s due at the time of submitting application

4-H County:

FFA School & Chapter:

Applicant’s Name: Phone: ( )

Address:

City: Zip:

Email:

Parents’ Name:

Have you ever attended Beef School? Yes No If yes, when? _____________

Number of Years 4-H or FFA Member: Boy Girl Age: Number of years showing Beef Cattle: Grade (as of Sept. 2015): I have shown in the following levels, check all that apply: County State National

PLEASE CIRCLE T-SHIRT SIZE --- Adult Small Adult Med. Adult Lg Adult XL List your major FFA or 4-H projects and activities:

Check the section that best applies to you:

I have never shown beef cattle before.

I have a little beef showing experience.

I have shown in numerous county and some state shows.

I am an advanced showman, having shown in numerous state and national shows.

Each 4-H or FFA member will bring his/her own calf. This calf must be halter broke. Either heifers or steers are acceptable (no bulls). Past show heifers are welcome. Tie and tack space will be provided. Club member must provide his/her own feed, hay, feed & water bucket, grooming equipment, halter and show stick, and tools for bed care. Registration fee is $200 which includes health and accident insurance for the 4-H or FFA member. Refunds made only if space is filled by another youth and requests must be made in writing by June 22, 2015. This fee also includes the following: 2 nights’ lodging at a local hotel; all meals (beginning with

lunch on Monday, June 22, and ending with lunch on Wednesday, June 24); entrance to all labs and lectures, Beef School notebook and Beef School t-shirt. The program for the Beef School is a full one. Participants will be expected to attend all labs, lectures, demonstrations and evening programs. The 4-H & FFA members will be well supervised. Parents and guests are invited to a Graduation and Team Fitting Contest on Wednesday. Participants will not be permitted to use cars or trucks at Beef School. We will provide a bus to transport students from the Ag Center to the hotel each day, with a driver from Carroll County School Systems.

TO BE COMPLETED BY AN AGENT, AG. ED TEACHER OR LEADER!

In the following space, please give a more detailed explanation of the showing ability of this 4-H or FFA member.

_____________________________________________________________________________________

Recommendation of County Extension Agent or Agriculture Education Teacher:

_____________________________________________________________________________________ ************************************************************ No applications accepted without this signature ************************************************************ County Extension Agent or Ag Ed Teacher If selected to attend, I will abide by all regulations and participate in all school activities. I understand that, should I fail to abide by the rules of the Beef School and the Code of Conduct, I will be subject to disciplinary action and my parents will be notified and requested to withdraw me from the school. ____________________________________ 4-H or FFA Member I approve of my child participating in this school. I understand that I may pick up my child and calf after 1:00 p.m. on Wednesday, June 24. All participants must be picked up no later than 2:00 pm. ____________________________________ Parent or Guardian Does this child require any special medication/medical attention? If so, please attach a statement. Return this form by June 1, 2015, TO: Christa Steinkamp

Georgia Beef School / Georgia Agriculture Education 216 Four Towers, UGA, Athens, GA 30602 (706) 552-4460 office (706) 552-4462 fax

**Please make all checks payable to: North Region FFA.

Teen Leader Application 2015 Georgia Beef School Carroll County Ag Center, 900 Newnan Road, Carrollton, GA - June 22-24, 2015

Applications due no later than June 1, 2015.

Must be signed by County Extension Agent or Agriculture Education Teacher. $100 Fee’s due at the time of submitting application

4-H County:

FFA School & Chapter:

Applicant’s Name: Phone: ( )

Address:

City: Zip:

Email:

Parents’ Name:

Number of Years 4-H or FFA Member: Boy Girl Age:______ Number of years showing Beef Cattle: Grade (as of Sept., 2015): ________ I have shown in the following levels, check all that apply: County

State National

PLEASE CIRCLE T-SHIRT SIZE --- Adult Small Adult Med. Adult Lg Adult XL List your major FFA or 4-H projects and activities:

Please answer the following questions:

Have you ever attended Beef School? Yes No If yes, when? ______

I have shown beef cattle: Less than 3 years More than 3 years

Select the section that best applies to you:

I have shown in numerous county and some state shows.

I have shown in several regional and national shows. Registration fee is $100 which includes health and accident insurance for the 4-H or FFA member. This fee also includes the following: 2 nights’ lodging at a local hotel; all meals (beginning with lunch on Monday, June 22, and ending with lunch on Wednesday, June 24); entrance to all labs and lectures; and a Beef School Notebook and t-shirt. Teen leaders are not allowed to bring a calf.

Teen Leader Application 2015 Georgia Beef School Carroll County Ag Center, 900 Newnan Road, Carrollton, GA - June 22-24, 2015

The program for the Beef School is a full one. Participants and Teen Leaders will be expected to attend all labs, lectures, demonstrations and evening programs. The 4-H & FFA members will be well supervised. Parents and guests are invited to a Graduation and Team Fitting Contest on Wednesday. Participants and Teen Leaders will not be permitted to use cars or trucks at Beef School.

TO BE COMPLETED BY AN AGENT, AG ED. TEACHER OR LEADER! In the following space, please give a more detailed explanation of the showing ability of this 4-H or FFA member.

Recommendation of County Extension Agent or Agriculture Education Teacher:

************************************************************ No applications accepted without this signature _______ ************************************************************ County Extension Agent or Ag Ed Teacher If selected to attend, I will abide by all regulations and participate in all school activities. I understand that, should I fail to abide by the rules of the Beef School and the Code of Conduct, I will be subject to disciplinary action and my parents will be notified and requested to withdraw me from the school. ____________________________________ 4-H or FFA Member I approve of my child participating in this school. I understand that I may pick up my child after 1:00 p.m. on Wednesday, June 24. All participants must be picked up no later than 2:00 p.m. ____________________________________ Parent or Guardian Does this child require any special medication/medical attention? If so, please attach a statement. Return this form by June 1 2015, TO: Christa Steinkamp

Georgia Beef School / Georgia Agriculture Education 216 Four Towers Building, UGA Athens, GA 30602 (706) 552-4460 office

(706) 552-4462 fax **Please make all checks payable to: North Region FFA.

Adult Leader Application 2015 Georgia Beef School Carroll County Ag Center, 900 Newnan Road, Carrollton, GA - June 22-24, 2015

DUE TO: Christa Steinkamp in Athens by June 1, 2015

COST: $100.00 --COVERS MEALS, LODGING, BEEF SCHOOL T-SHIRT (Due when you apply)

Name of Applicant: Age: County: Street Address: Gender: M F City, State: ZIP: Phone: ( ) Email: Major Responsibilities as a 4-H or FFA Leader/Volunteer: Experiences with Youth Beef Project: Do you have a child applying to Beef School? Yes No If so, what is his or her name? __________________________________ Check your Experience Group below. NOTE: Parents of Beef School attendees will be assigned to a group that their child is not in. ______I know the basics. I have been supervised youth Beef Projects for less than three (3) years. I feel that I am moderately experienced with youth Beef Projects. I have supervised Beef Projects over three

years. I feel that I am experienced with youth Beef Projects. I have supervised participants at State, Regional and

some National Shows.

Tell us why you would like to attend this school as a Volunteer Leader: Have you been to Beef School as an adult leader before? ________ When? _________________

PLEASE CIRCLE T-SHIRT SIZE --- Adult Small Adult Med Adult Lg Adult XL Registration fee is $100 which includes health and accident insurance. Refunds made only if space is filled by another approved adult and requests must be made in writing by June 22, 2015. This fee also includes the following: 2 nights’ lodging at a local hotel; all meals (beginning with lunch on Monday, June 22, and ending with lunch on Wednesday, June 24); entrance to all labs and lectures; Beef School notebook and t-shirt.

Are you certified in any medical training? _ If so please specify: _ Note to Extension Agents -- Only Adult Volunteer Leaders who are now, or intend to be, active 4-H Beef Project Club Leaders should be nominated for one of these positions. ALL ADULTS MUST HAVE COMPLETED THE CERTIFIED OVERNIGHT CHAPERONE TRAINING.

Extension Agent / Agriculture Education Teacher -- Please give us your recommendation of this applicant. County Extension Agent/Ag. Ed Teacher It is understood that, if selected to attend 2015 Beef School, I will accept the responsibilities assigned for supervision of 4-H and FFA members at the hotel and at the school. Signature of Applicant RETURN TO: Christa Steinkamp Georgia Beef School / Georgia Agriculture Education 216 Four Towers Building, The University of Georgia Athens, GA 30602 **Please make all checks payable to: North Region FFA.

Due ON or BEFORE June 1, 2015!

2015 CODE OF CONDUCT Beef School

Name: FFA Chapter: Grade:

BEHAVIOR STANDARDS All rules and regulations governing the program activities and events will be discussed with agents, teachers, leaders, and participants. This Code of Conduct is valid for the duration of the event including travel to and from the event. Participants are expected to attend all sessions as part of a planned program exhibiting positive character and behavior including (but not limited to) trustworthiness, responsibility, respectfulness, caring, citizenship and fairness.

• Participants are expected to be responsive to the reasonable requests of the leaders and respectful of the needs for their personal safety and the safety of others.

• Participants should dress appropriately, use appropriate language and respect the rights of others. • Participants may not use alcohol, drugs, or tobacco, nor be associated with or remain in the presences of others using the

substances. • Participants may not behave recklessly, engage in sexual misconduct, assault, threaten or harm another person nor may they misuse

or abuse public or private property. • Realizing these guidelines are not “all inclusive” the University of Georgia Extension Staff, leaders and Ag. Education Staff reserve the

right to make adjustments to these policies

CONSEQUENCES OF MISBEHAVIOR Participants and adults who observe a breach in the Code of Conduct should report the misbehavior to the appropriate leader. Participants misbehaving will have the opportunity to explain their actions to leaders in charge of the activity and may request a review board. The person coordinating the event may also convene a review board for the purposes of determining what has occurred and what disciplinary action should be taken. A review board will consist of one faculty or staff member, one Agriculture Education staff member, two volunteers and three participants. The Extension faculty member coordinating the event will serve as chairperson. Disciplinary action should only be discussed with those involved, their parents/guardians and their leaders.

If the participant is found in violation of the actions listed below and receives disciplinary action issued through the review process, his/her parents/guardians will be notified; the participant may be sent home at the parents’ expense and may be suspended from participation in events for a period of no more than 6 months:

Breaking curfew or disturbing the peace, Unexcused absences from the activities of an event, Unauthorized use of vehicles during the event, Reckless behavior, Use of foul or offensive language, Possession or use of tobacco, Remaining in the presence of those using alcohol, illegal drugs or tobacco.

If the accused is found in violation of the items below, his/her parents/guardians will be notified, the participant may be sent home at the parents’ expense and suspended from participation of events for a period of no more than 12 months:

Possession or use of illegal drugs or alcoholic beverages, Theft, misuse or abuse of public or personal property, Sexual misconduct, Possession of weapons or fireworks, Unauthorized absence from the premise of the event, or Assault or personal harm.

In extraordinary cases, the review board may recommend suspense exceeding those listed above. If a participant wishes to appeal the decision of the review board, the participant must appeal in writing through the County Extension office or Agricultural Education office. Appeals must be filed within 10 days of notification of the disciplinary action. If the staff can not resolve the matter, an appeal board will meet within 30 days of the Participants request. The appeal board will consist of one faculty/staff member, two volunteers and three participants.

Participant’s Agreement

I have read the FFA Beef School Code of Conduct and agree to participate fully in all aspects of program activities. I understand the standard of behavior and agree to maintain such during 2015 Beef School.

_____________________________________________________________ ____________________ Participant’s Signature Date

2015 Georgia Beef School

Parental Consent and Medical Form Please thoroughly read and complete BOTH sides of this form

The Undersigned, Being a Parent or Guardian of (insert name of minor) releases its representatives, agents, servants, and employees from liability for any injury to said minor, resulting from any cause whatsoever occurring to said minor at any time while attending the 2015 Georgia Beef School including travel to and from camp, excepting only injury or damage resulting from willful acts of such representatives, agents, servants and employees. The Georgia Beef School, University of Georgia, Georgia Cooperative Extension, and Georgia FFA Association are also released of any expenses for resulting from the injury. To protect the safety of your child and other students, the 2015 Georgia Beef School has no-tolerance policies that immediately result in students being sent home. These policies are:

1. Use of violence or possession of weapons 2. Use of alcohol or drugs 3. Entering the room of the opposite sex 4. Being outside the room after curfew

Parents or guardians of students who violate these policies will be notified to pick up their child. Please stress to your child the importance of obeying all policies of Beef School and the advisor / agent. NOTE TO TEACHERS / AGENTS: Please have this form reproduced and see that each minor attending camp gets it completed and signed. If possible, reproduce this form on front and back for ease of handling. Collect these before leaving home, make sure you have them on the bus, and turn them in when you register. We suggest that you make a copy of this form for your information and protection. Without this on file NO medical treatment of any kind can be rendered. PLEASE COPY THE PARENTAL CONSENT/MEDICAL RELEASE ON FRONT AND BACK OF ONE PAGE (Continued on Back)

FFA Chapter: ______________________________ Advisor: __________________________________ Student: ___________________________________

____ Male ____ Female

Medical Release Form

1. Student Name________________________________________Chapter ____________________________ 2. Complete Address_______________________________________________________________________ 3. Social Security # ______ ____ _______ Date of Birth ________________________ 4. Name and Phone Number of Family Physician ________________________________________________ 5. LIST ANY & ALL ALLERGIES: ________________________________________________________ 6. LIST ALL CURRENT MEDICATIONS: __________________________________________________

_______________________________________________________________________________________ 7. Student’s Health History: (heart condition, diabetes, asthma, any injuries) ___________________________

______________________________________________________________________________________ If you have ever been diagnosed with asthma by a physician and have ever had medication including tablets, nebulizers, or inhalers, you MUST bring such treatment with you to camp or you will not be allowed to register!!

8. Any restrictions/medical conditions the nurse needs to be aware of: ________________________________ 9. Year of last immunization/immunity: Tetanus______ MMR_______ Hepatitis_______

Varicella/Chicken Pox _______ 10. In case of an emergency, provide contact information so that you can be notified at all times. In case of an emergency, contact: _______________________________________ Relationship to the student: ____________________________________________ Home Phone #: ( ) ________________________________________________ Work Phone #: ( ) ________________________________________________ Cell Phone #: ( ) ________________________________________________ Pager #: ( ) _____________________________________________________ 11. Secondary contact if above person can not be contacted.

Contact: ___________________________________________________________ Relationship to Student: ______________________________________________ Home Phone #: ( ) ________________________________________________ Work Phone #: ( )________________________________________________ Cell Phone #: _______________________________________________________ Pager #: ( )______________________________________________________

12. Please WRITE YES OR NO to the following medications your child may or may not be given: Tylenol______ Ibuprofen______ Pepto Bismol______ Tums_____ Sudafed_____ Benadryl______ Maalox______ Immodium______ Tussin Cough Syrup______ Glucose Tabs______ Visine______ Neosporin______ Hydrocortisone cream_______

I have read and understand the statements in this release form. I understand that should a health problem arise, I will be notified but if I can not be reached by telephone I consent to emergency medical treatment, which may include surgery for my child as deemed necessary by competent medical personnel. I also consent to the release of information for insurance purposes. Parent/Guardian Signature __________________________________________ Parent/Guardian (Please Print)________________________________________

GEORGIA 4-H CODE OF CONDUCT

BEHAVIOR STANDARDS The Georgia 4-H Code of Conduct is valid for one year and applies to all activities coordinated through Georgia 4-H.

4-H’ers are expected to attend all sessions as part of a planned program exhibiting positive character and behavior including (but not limited to) trustworthiness, responsibility, respectfulness, caring, citizenship and fairness.

4-H’ers are expected to be responsive to the reasonable requests of leaders and respectful of the needs for their personal safety and the safety of others.

4-H’ers should dress appropriately, use appropriate language and respect the rights of others.

4-H’ers may not behave recklessly or in a manner which prohibits others from participating in the program in the manner intended.

4-H’ers may have access to technology at UGA/CES offices and facilities. Technology use is for educational purposes. 4-H’ers may not access inappropriate websites or materials.

Realizing these guidelines are not “all inclusive” the University of Georgia Extension staff and volunteers reserve the right to make adjustments to these policies.

CONSEQUENCES OF MISBEHAVIOR 4-H’ers and adults who observe a breach in the Code of Conduct must report the misbehavior to the appropriate leader. The leader will complete an incident report and determine the next steps regarding the incident.

If 4-H’ers are found participating in actions listed below, law enforcement or other legal authorities may be notified and may lead the review and consequences related to the incident. In these incidents, 4-H’ers may be removed from the event and suspended or expelled from future 4-H participation. These behaviors may include, but are not restricted to:

Possession or use of illegal drugs

Possession or use of a weapon

Assault or harassment

Inappropriate sexual behavior

If the 4-H’er is found participating in the actions listed below, 4-H leaders may be notified and may lead the review and consequences related to the behavior. 4-H’ers misbehaving will have the opportunity to explain their actions to leaders in charge of the activity and may request a review board. The person coordinating the event may also convene a review board for the purposes of determining what has occurred and what disciplinary action should be taken. A review board will consist of one Extension faculty or staff member, two volunteers and three 4-H members. The Extension faculty member coordinating the event will serve as chairperson. In some cases, incidents are deemed serious and may be referred to law enforcement or other legal authorities. If the 4-H’er receives consequences from the leader or through the review process, his/her parents/guardians may be notified; the 4-H’er may be sent home at the parents’ expense and may be suspended from participation in 4-H events. Suspensions may be up to one year. If a 4-H’er wishes to appeal the decision of the review board, the 4-H’er must appeal in writing through the County Extension office. Appeals must be filed within 10 days of notification of the disciplinary action. The appeal is sent to the Program Development Coordinator of the 4-H member and the State 4-H Leader for ruling by the State 4-H Leader. Following any disciplinary review, the person coordinating the activity will provide written notification to the appropriate parties including but not limited to the 4-H’er, his/her parent/guardian and his/her county Extension faculty member.

Breaking curfew or disturbing the peace

Unexcused absences from the activities or premise of an event

Unauthorized use of vehicles during the event

Reckless or inappropriate behavior

Use of foul or offensive language

Possession or use of alcohol or tobacco

Breach of the 4-H Code of Ethics

Remaining in the presence of those who are breaking the 4-H Code of Conduct

Theft, misuse or abuse of public or personal property

Possession of fireworks

PARENT/GUARDIAN & 4-H’er AGREEMENTS Release Waiver of Liability and Covenant Not to Sue I have read the Georgia 4-H Code of Conduct and agree to participate fully in all aspects of program activities. I understand the standard of behavior and agree to maintain such during 4-H programming.

____________________________________________________________________ ____________________ 4-H’ers Signature Date I have reviewed the Code of Conduct and agree to all of its provisions. For the sole consideration of the Cooperative Extension Service’s arranging for participation in 4-H programming, I hereby release and forever discharge The University of Georgia, the Board of Regents of the University System of Georgia, their members individually, and their officers, agents and employees from any and all claims, demands, rights and causes of action of whatever kind that I may have, either on my own behalf or in my capacity as a legal representative of my child, arising from or in any way connected with my child’s participation in 4-H. I further covenant and agree that for the consideration stated above I will not sue the Institution, the Board of Regents of the University System of Georgia, its members individually, its officers, agents or employees for any claim for damages arising or growing out my child’s participating in the program. I understand that the acceptance of this Release, Waiver of Liability, and Covenant not to sue the Board of Regents of the University System of Georgia shall not constitute a waiver, in whole or part, of sovereign immunity by said Board, its members, officers, agents, and employees. I certify that my child is participating in 4-H with my knowledge and consent. I have read and understand all of the above policies. I also give permission my child’s images, likeness, and voice to be used by the Board of Regents of the University System of Georgia by and on behalf of the University of Georgia in print or electronic form

_____________________________________________________________________________________ __________________ Parent/Guardian Signature Date Phone

VALID FOR ONE YEAR FROM DATE OF SIGNING

Revised November 2012

4-H’ers Name:_________________________________________________________County________________________________ Address:______________________________________________________________Phone________________________________ School:_______________________________________________________Grade:_____________________Year:_______________

Georgia 4-H Medical Information & Release Form

Event or Activity Date of Event/Activity

4-H’ers Information

Name County Address Date of Birth Grade Gender Cell Phone (if applicable)________________

Parent/Guardian Information Name: Phone: Cell Phone: Name: Phone: Cell Phone:

Please list the names of two adults other than parent/guardian who may be contacted in case of emergency. Name: Phone: Cell Phone: Name: Phone: Cell Phone:

Medical Information

The following information is requested in case of accident or illness to better treat your child. The information is optional and not required for participation in the 4-H event or activity.

Name of Physician: Phone:

Date of Last Physical Examination: Drug Allergies:

Other Allergies Describe any recent illness or injury

Describe any pre-existing conditions

Describe any other circumstances that would help leaders or medical professionals in working with the 4-H’er

PARENT/GUARDIAN AGREEMENT: I understand that should a health problem arise, I will be notified but that if I can not be reached by telephone, such medical treatment, including surgery, as deemed necessary by competent medical personnel could be rendered; that such necessary information may be released for insurance purposes and that I understand the limitation of the coverage as indicated below. Furthermore, I am aware that participation in this event includes risk including, but not limited to, transportation to/from event, sports and recreational games, ropes courses, water activities, hiking, as well as risks that are not foreseeable. For the sole consideration of the Cooperative Extension Service’s arranging for participation in 4-H programming, I hereby release and forever discharge The University of Georgia, the Board of Regents of the University System of Georgia, their members individually, and their officers, agents and employees from any and all claims, demands, rights and causes of action of whatever kind that I may have, either on my own behalf or in my capacity as a legal representative of my child, arising from or in any way connected with my child’s participation in 4-H. I further covenant and agree that for the consideration stated above I will not sue the Institution, the Board of Regents of the University System of Georgia, it’s members individually, its officers, agents or employees for any claim for damages arising or growing out my child’s participating in the program. I understand that the acceptance of this Release, Waiver of Liability, and Convent not to sue the Board of Regents of the University System of Georgia shall not constitute a waiver, in whole or part, of sovereign immunity by said Board, its members, officers, agents, and employees. I certify that my child is participating in 4-H with my knowledge and consent. I have read and understand all of the above policies. I also give permission my child’s images, likeness, and voice to be used by the Board of Regents of the University System of Georgia by and on behalf of the University of Georgia in print or electronic form.

____________________________________ _____________ Parent/Guardian Signature Date

INSURANCE COVERAGE INFORMATION (to be completed by county Extension personnel) Insurance for the event/activity has been purchased as indicated. For complete details of coverage, please contact the county Extension Office.

____Insurance for Summer Camp at Georgia 4-H Centers ______American Income Life Insurance (Plan 3) _____American Income Life Insurance (Dollar a Year Plan) ______Other Insurance Plan

PLEASE COMPLETE BOTH SIDES

Over the Counter & Prescription Medication Summary 4-H’ers Name County Please list any/all medication currently being taken by the 4-H’er including prescription and over the counter medications. Additionally, parent/guardian should list any over the counter medication that may be given to the 4-H’er in case of illness. 4-H personnel may not administer over the counter or prescription medication without parental/guardian approval unless prescribed by medical personnel. 4-H’ers are expected to provide all medication(s) listed and administer the medication. If health facilities and/or personnel are available at the facility, a request may be made prior to the event to have medication administered by trained personnel. Additional copies of this page may be made as necessary.

Name of Medication:_______________________________________________________________________________________________________________________ Illness/condition is medication being taken for:_____________________________________________________________________________________ Describe dosage and special instructions:_____________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Name of Medication:_______________________________________________________________________________________________________________________ Illness/condition is medication being taken for:_____________________________________________________________________________________ Describe dosage and special instructions:_____________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Name of Medication:_______________________________________________________________________________________________________________________ Illness/condition is medication being taken for:_____________________________________________________________________________________ Describe dosage and special instructions:_____________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Name of Medication:_______________________________________________________________________________________________________________________ Illness/condition is medication being taken for:_____________________________________________________________________________________ Describe dosage and special instructions:_____________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________

I am the parent/guardian of ________________________________________and give permission for the medications listed to be administered to as directed.

__________________________________________ _______________ Parent’s signature Date

PLEASE COMPLETE BOTH SIDES April 20, 2012