TO: FROM: DATE: SUBJECT:

Parents/ Guardians Autumn N. Starcher, Ph.D., Extension Agent, 4-H Youth Development April 7, 2017 Cabell County 4-H Camp Registration Packet

We are so happy you are considering joining us at a 2017 Cabell County 4-H Camp! Included in this packet is information about the camp registration process. Please review all of the enclosed information. If you have any questions, please do not hesitate to call the Extension Office at 304-743-7151. Early Bird camp registration will be accepted until April 28 or when camps are full – whichever comes first - and general registration will be open until May 15. Please keep the outside sheet as it contains useful information for your reference.

CHECKLIST - CAMP REGISTRATION FORMS & PAYMENT

Check (√) when completed (the forms are color coded for each reference).

______ Camp Registration Form – Please fill in all information (GREEN - p. 5). ______ Health History Form - fill in all information on both sides. Please make sure that emergency contact info is up

to date (WHITE - p.6-7). ______ Code of Conduct & Parental Release – Please read carefully and sign as appropriate. The Code of Conduct

outlines acceptable/unacceptable behavior at camp and the consequences for unacceptable behavior. In the Release Authorization section, please put the names of those people authorized to pick up your child, but do not sign (LIGHT BLUE - p.8-9). Parents/guardians will sign this section at time of pick up.

______ Media Release – Please fill this out and sign (PINK - p.10). ______ Free & Reduced Price School Meals Family Application* - please fill out completely if your child qualifies (WHITE -

p.12-14)______ Special Dietary Needs - please fill out completely if applicable (YELLOW - p.11) ______ Class Selection – Please rank your top choices and return as soon as possible. Classes are filled on a first come,

______

______

______

first served basis. Please make sure you fill out the appropriate form. (WHITE - p. 16)Camp Payment and Payment form– make checks payable to Cabell County 4-H Foundation. See the next page for more information. (WHITE - p.15)Permission to Transport - If your camper wants to go to the pool at Guyan Estates for afternoon recreation, you must complete the Permission to Transport form (PINK - p.17)18+ year-old 4-H'er Vetting Forms - If your camper will be 18 years of age on June 5, 2017, then they must complete and return this application and all trainings by April 28 (WHITE - p.18-25). NO EXCEPTIONS!

If ALL forms are not properly completed, they will be returned to you for correction.

4-H CAMP DATES & OTHER PERTINENT INFORMATION

CAMP DATES LOCATION CHECK IN CHECK OUT 4-H Older Camp June 5-9 4-H Camp 9:00 a.m. on June 5 12:00 p.m. on June 9

4-H Younger Camp June 12-16 4-H Camp 9:00 a.m. on June 12 12:00 p.m. on June 16

Cloverbud Day Camp June 19-22 4-H Camp 9:00 a.m. daily 2:00 p.m. daily

Return ALL completed forms to: Cabell County Extension Office

Attn: 4-H Camp 2726 Howells Mill Rd

PO Box 219Ona, WV 25545

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2017 4-H CAMP FEES Make all Checks Payable to Cabell County 4-H Foundation

A. Older & Younger Full Camp Fee:

Early Bird Registration by April 28 $100.00 $55.00 (Completed Free & Reduced Price Family Application must be returned with registration forms)

B. Cloverbud Day Camp Full Camp Fee: $50

MEDICAL ISSUES: Please read and complete the Health History Form. These forms do not need to be signed by a doctor. They do need to contain complete information.

• All meds must be sent to camp in their original containers. Please send only enough medication for the week.• Camp health care provider may dispense over-the-counter meds (such as Tylenol). Please identify which over-the

counter meds your child takes routinely on the back page of the Health History Form.• There is a health care provider who is on duty 24 hours/day who treats all minor ailments.• 911 will be called for campers with more serious problems. The parent/ guardian will be notified immediately.

AGE REQUIREMENTS: Older Camp: Youth must be 13 years by the start of Older Camp on June 5. Younger Camp: Youth must be 9 years by the start of Younger Camp on June 12. Both 4-H Older & Younger Camps are residential or overnight camps. Cloverbud Day Camp: Youth must be 5 years old by the start of the Cloverbud Day Camp on June 19.

CAMPER SUPERVISION: The American Camping Association (ACA) as well as WVU Extension Service have set standards regarding how many campers one 4-H volunteer can effectively supervise. These ratios are based on camper ages and are as follows: 1 staff per 6 kids ages 6-8; 1 staff per 10 kids ages 9-14; 1 staff per 12 kids ages 15-18. Volunteers and 4-H Teen Camp counselors are trained prior to attending camp.

DUTIES (FOR OVERNIGHT CAMPS ONLY): Campers are expected to keep the barracks clean and orderly, and to do their part in keeping the camp grounds and buildings neat. Campers are grouped according to tribes and a list of their duties for each day is cited in the Camp Program Booklet and is posted at camp.

TELEPHONE: The phone number for Autumn Starcher, the Camp Director’s cell phone is 304-531-0689. This phone number should be called for emergencies only.

Regular Registration (April 29 - May 15)No late registration or walk-ins will be accepted!

$125.00 $80.00 (Completed Free & Reduced Price Family Application must be returned with registration forms)

Please indicate on the front page if you are paying 1) the full amount, 2) a deposit of $25 with the remainder due May 15, or 3) your club is paying for your registration. No refunds will be issued after May 15, 2017.

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CAMP CODE OF CONDUCT INFORMATION

Each participant is to take a full and active interest in all parts of the planned program including attending all scheduled functions. A camper may be sent home if involved in any of the following:

1. Deliberate destruction of facilities or equipment.2. Deliberate and willful failure to respond to adult supervision.3. Possession or use of fireworks, weapons, knives, or items that can be used as a weapon except under adult

supervision in activities.4. Pranks, initiation, bullying or hazing of any kind.5. Deliberate or threatening behavior to others or themselves such as fighting or threats.6. Possession or use of alcoholic beverages, illegal drugs, or tobacco products.7. Girls visiting boys' or boys visiting girls' sleeping rooms.8. Curfew violations as specified during the event.9. Failure to attend and participate in scheduled activities.10. All participants are to be accounted for by staff. Those not where they are assigned to be, by the time specified, will

be reported to the Camp Director. When in camp, any camper not where they should be 15 minutes after the timespecified may be sent home.

4-H campers will be advised of general camp rules the first day of camp. Infractions or unacceptable conduct will bereviewed by the camp leadership: to include but not limited to the involved volunteers or camp staff for relevant action.Any conduct not specifically covered by the above provisions, but deemed inappropriate by the camp leadership will beviewed a serious breech of decorum, (such as vandalism, fighting, profanity, stealing, etc.) and appropriate action will betaken.

CHECKLIST – WHAT TO BRING & WHAT NOT TO BRING! FOR RESIDENTIAL CAMPS I.E. 4-H OLDER & YOUNGER CAMPS Do not bring anything to camp that you would be upset about if you lost it.

NECESSARY ITEMS: _____ Comfortable clothes (T-shirts, shorts, etc.) - enough for 5 days for Younger Camp & Older Camp _____ A pair of comfortable shoes _____ Towels _____ Sheets & blanket for single bed, OR sleeping bag _____ Pillow _____ Personal items (Toothbrush, toothpaste, soap, shampoo, deodorant, etc.) _____ Sunblock SPF 15 or higher _____ Water bottle _____ Bag for wet/dirty clothes _____ Jeans and light jacket, in case of cool nights _____ Rain gear

CAMPERS ARE ASKED TO DRESS APPROPRIATELY WITH GOOD TASTE AND MODESTY IN MIND.

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Remember forbidden items

will be collected by staff and returned

after camp!

FORBIDDEN ITEMS

Please DO NOT send these items to camp with campers or teen leaders. They will be collected by staff and returned after camp.

Cell phones or pagers Radios, iPods, walkmans, CD players, DVD players, etc. Video games, game boys, etc. Anything expensive (jewelry, etc.) Any item forbidden in the Code of Conduct Pokemon, Magic Cards or other trading cards Food - is not allowed in the cabins and will be confiscated if found. Food is a risk to youth with food allergies; it also

invites bugs during the hot summer months.

TYPICAL DAY AT 4-H CAMP

Following is a typical “Daily Schedule” for the campers during their week at either Older or Younger Camp. (Monday, the day of arrival and Friday, the day of departure is different).

Cloverbud Day Camp follows a similar schedule but starts at 9:00 a.m. and ends at 2:00 p.m. daily. There is no swimming at Cloverbud Day Camp.

7:30 a.m.

12:00 p.m.

5:00 p.m.

Rise and Shine/ Flag Raising Flag Raising Breakfast Cabin Clean-up/Gather Items for Class Time Classes I & II Tribal Meetings

Lunch Class 3Afternoon Assemblies and Group Recreation (examples: Pool, Heros4Higher, Water Relay, Talent Show)

Dinner Evening Assembly and Group Recreation Council Circle Evening Recreation and Social Time (examples: Carnival, Karaoke, Makerspace)Cabin Meetings Lights Out (approximately 11:30 p.m.)

Activities will vary day to day

4-H: Making the Best Better… in Cabell County!

Programs and activities offered by West Virginia University Extension Service are available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political beliefs, sexual orientation, national origin, and marital or family status. Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Director, Cooperative Extension Service, West Virginia University.

Return ALL completed forms to:

Cabell County Extension Office Attn: 4-H Camp 2726 Howells Mill Rd

PO Box 219 Ona, WV 25545

Questions? Contact the Extension Office at

304-743-7151 or email:autumn.starcher@mail.wvu.edu

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2017 Cabell COUNTY 4-H CAMP REGISTRATION FORM

Please check (√) the camp you will be attending:

____ 4-H Older Residential Camp: June 5 - 9 (Youth must be 13 years old by the start of camp on June 5)

____ 4-H Younger Residential Camp: June 12 - 16 (Youth must be 9 years old by the start of camp on June 12)

____ Cloverbud STEM Day Camp: June 19 - 22 (Youth must be 5 years old by the start of the camp on June 19)

PLEASE FILL OUT THE INFORMATION BELOW (PLEASE MAKE SURE TO THOROUGHLY COMPLETE EVERY ITEM BELOW!) Camper’s Full Name _________________________________________________________________________________

Preferred Name (for Name Tag) ________________________________

Male Female Birth Date: ______________________ Age at Start of Camp**: ____________

This will be my year at 4-H Camp (not including Cloverbud Day Camp) Last Grade Completed: _____________

Parent/Guardian Name _______________________________________________________________________________

Address ______________________________________________________ __ State: _____ Zip Code:______________

E-mail ____________________________________________________________________________________________

Phone _____________________________________ Cell __________________________________________

4-H Club (if applicable) _______________________________________________________________________________

What School Do You Attend ___________________________________________________________________________

How many in your family will be coming as campers this year ________________________________________________

Does your child require accommodation? ____________________________________________________________ _________________________________________________________________________________________________

T-SHIRT SIZE - Cost of T-Shirt is $5 (due with registration form)Please check (√) your size: __Youth S __ Youth M __Youth L __ Adult S __Adult M __Adult L __Adult XL

COMPLETE THE FOLLOWING REGARDING TRIBAL INFORMATION (NOT APPLICABLE FOR DAY CAMP) IF YOU HAVE BEEN TO OLDER OR YOUNGER CAMP, what is your tribe? ______________________________________________ IF YOU HAVE NOT BEEN to Older or Younger Camp, what tribe would you like to be in? _____________________________ The tribes include: Cherokee, Delaware, Mingo, and Seneca. Campers do a variety of activities as well as Council Circle (a camp fire) with their tribe every day at camp. Check √ the appropriate box if you have been to Younger Camp as a Chief Sag Check √ the appropriate box if you have been to Older Camp as a Chief Sag

**18-21 Year Olds must call the Cabell Co. Extension Office by April 14 if they plan to attend Older Camp this year. New requirements are in place (that require time), that must be completed to attend Older Camp. Ph. 304-743-7151.

OFFICE USE ONLY Date: ______________________ Time: ______________________

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Health History Form: 4-H Camps, Energy Express, Events, and Activities

Provide complete information and return this form with event registration. At event arrival, update information with health personnel.

EE-000-12

I understand that while all reasonable efforts will be made to provide a safe environment, certain risks are involved. I understand the State of West Virginia, West Virginia University, its Board of Governors, officers, employees, and agents are not liable in case of accidental injury or illness. I hereby further understand that in case of serious injury or illness, I will be notified. If it is impossible to contact me, I hereby give permission for emergency treatment or surgery as the attending physician recommends.

This health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp

My child has my permission does not have my permission to participate in Energy Express

should not participate in the following activities ______________________________________________________________

Signature of parent/guardian _______________________________________________________ Date __________________________

I also understand and agree to abide by any restrictions placed on my participation in Energy Express.

Signature ______________________________________________________________________ Date __________________________

PERMISSIONS: Important – This section must be completed for child to participate in Energy Express.

Name ________________________________________________________________________________________________________________

Home address ______________________________________________________________________________________________________

Gender: Male Female Birth date ________ / ________ / ________ Age at event ___________

CUSTODIAL PARENT/GUARDIAN _________________________________________________________ Phone ______________________

Home address (if different from above) ___________________________________________________________________________________

Home phone ( ) ______________________ Work phone ( ) ______________________ Other ( ) ______________________

SECOND PARENT OR GUARDIAN OR EMERGENCY CONTACT _____________________________________________________________

Address ___________________________________________________________________________ Phone __________________________

If not available in an emergency, notify ____________________________________________________________________________________

Relationship _______________ Phone _________________ Address __________________________________________________________

INSURANCE INFORMATION: Is the participant covered by family medical/hospital insurance? Yes No

If so, indicate carrier or plan name _______________________________________________________ Group # ________________________

Insurance carrier address _______________________________________________________ Phone number __________________________

ALLERGIES: List all known. Describe reaction and management of the reaction.

Medication allergies (list) Food allergies (list) Other allergies (list) – include insect stings, hay fever, asthma, animal dander, etc.

______________________ ______________________ _________________________________________________________________

______________________ ______________________ _________________________________________________________________

______________________ ______________________ _________________________________________________________________

Last First Middle

Street address City State Zip

Name

Street address City State Zip

Street address City State Zip

Street address City State Zip

Name

Name

activities except as noted. I hereby give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any recordsnecessary for treatment, referral, billing, or insurance purposes. I give permission to the camp to arrange necessary relatedtransportation for me/my child. In the event I cannot be reachedin an emergency, I hereby give permission to the physicianselected by the camp to secure and administer treatment,including hospitalization, for the person named above. Thiscompleted form may be photocopied for trips out of camp.

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MEDICATIONS BEING TAKEN:

Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time of this event. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.

This person takes NO medications on a routine basis. OR This person takes medications as follows:

Med #1 _____________________ Dosage ________ Specific times taken each day ______ Reason for taking __________________________

Med #2 ____________________ Dosage ________ Specific times taken each day ______ Reason for taking __________________________

Attach additional pages for more medications.

Identify any medications taken during the school year that participant does/may not take during the summer. ____________________________

___________________________________________________________________________________________________________________

GENERAL QUESTIONS: (Explain “yes” answers below.)

Has/does the participant: Yes No1. Had any recent injury, illness, or infectious disease? 2. Have a chronic or recurring illness/condition? 3. Ever been hospitalized? 4. Ever had surgery? 5. Have frequent headaches? 6. Ever had a head injury? 7. Ever been knocked unconscious? 8. Wear glasses, contacts, or protective eye wear? 9. Ever had frequent ear infections?

10. Ever passed out during or after exercise? 11. Ever been dizzy during or after exercise? 12. Ever had seizures? 13. Ever had chest pain during or after exercise? 14. Ever had high blood pressure? 15. Ever been diagnosed with a heart murmur?

Yes No16. Ever had back problems? 17. Ever had problems with joints (e.g., knees, ankles)? 18. Have an orthodontic appliance being brought to

the event?19. Have any skin problems (e.g., itching, rash, acne)? 20. Have diabetes? 21. Have asthma? 22. Had mononucleosis in the past 12 months? 23. Had problems with diarrhea/constipation? 24. Have problems with sleepwalking? 25. If female, have an abnormal menstrual history? 26. Have a history of bed-wetting? 27. Ever had an eating disorder? 28. Ever had emotional difficulties for which professional

help was sought?

Name of family physician ___________________________________________________________ Phone _____________________________

Name of family dentist/orthodontist ___________________________________________________ Phone ____________________________

Which of the following has the participant had? Measles Chickenpox German measles Mumps Hepatitis A Hepatitis B Hepatitis C

Please explain any “yes” answers, noting the number of the questions.

# ____ ___________________________________________________________________________________________________________

# ____ ___________________________________________________________________________________________________________

Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the camp should know.

______________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Please give all dates of immunizationVaccine: Dates: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Diptheria _________ _________ _________ _________ _________ _________ Pertussis _________ _________ _________ _________ _________ _________ Tetanus _________ _________ _________ _________ _________ _________ Polio _________ _________ _________ _________ _________ _________

Typhoid _________ _________ _________ _________ _________ _________

TB Mantoux Test Date of last test ________________ Positive Negative

SCREENING RECORD (For staff use only) Screened by ________________________________________________________________

Date screened ____________ Time _______ AM / PM Updates/additions to health history noted Yes No None required

Meds received ___________________________________________________________________________________________________

Current health needs identified ______________________________________________________________________________________

Observational notes _______________________________________________________________________________________________

To request disability accommodations for state WVU Extension events, contact Energy Express, 766 Allen Hall, PO Box 6602, Morgantown, WV 26506-6602, phone 304-293-3855, or fax 304-293-3866.

Programs and activities offered by the West Virginia University Extension Service are available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political beliefs, sexual orientation, national origin, and marital or family status. Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Director, Cooperative Extension Service, West Virginia University. 4H13-22 7

Participant Name: _____________________________________________________________________ 4-H Member Code of Conduct 2016-2017

WEST VIRGINIA 4-H MEMBER CODE OF CONDUCT

While attending 4-H camp, activities and events, I will: • Obey all rules established by the local, state, and national 4-H program, event/program facilities,

and all local, state, and federal laws.• Conduct myself in a courteous manner with others, refraining from the use of profanity or language

that is disrespectful and making sure my conduct and participation in 4-H projects, programs, exhibits, and other4-H activities is above all honest, courteous, and fair.

• Respect the authority of adult volunteers, youth leaders, 4-H staff, and others in leadership roles.• Refrain from possession, transport, or use of firearms, bows and arrows, knives, and other implements of harm

except within the context of an approved shooting sport, archery, or similar educational programs.• Refrain from the use, transport, or possession of alcohol, drugs, or tobacco. If I encounter anyone using these

substances, I will leave their presence immediately and report the incident to adult leaders or program staff.• Not tamper nor use without permission, or otherwise harm clothing, belongings, or other personal property of

participants, staff, or volunteers.• Respectfully use the facilities, equipment, and grounds made available by the W.Va. 4-H program.• Remain in the appropriate, assigned program area at all times and dress appropriately for each event.• Engage in respectful behavior toward my peers, being careful to avoid hazing, pranking, and initiations that involve

humiliation, embarrassment, or targeting individuals.• Make an effort to include all participants in activities.• Respect local, state, and national 4-H program social media rules and guidelines, and refrain from creating,

possessing, or transferring any images that are illegal or disrespectful toward others or the 4-H program. Inaddition, where appropriate, I will ask permission before I take or transfer images of those participating in 4-Hactivities.

MEMBER CONSEQUENCES

Unacceptable behavior during a 4-H program/event (as defined within this Code of Conduct or through a review process by 4-H staff/volunteer) will result in consequences to the participant. Consequences may include:

1. Early release from this 4-H program/event without refund,2. Restitution or repayment of damages,3. Denial of future participation in the 4-H program/event at the local, district, state and national levels for one or

more years (as determined by the unit staff in charge of, or responsible for, the 4-H program/event),4. Forfeiture of financial support for a 4-H program/event5. Removal from 4-H offices held (if applicable), and6. Releasing the youth to the appropriate law enforcement agency and/or the proper authorities.

NOTE: Any conduct not specifically covered by this Code of Conduct, but deemed inappropriate by those responsible for the 4-H program/event will be viewed as a violation and appropriate action will be taken. If an infraction occurs, the person incharge of the 4-H program/event will provide appropriate communication to parents/guardians.

SEE NEXT PAGE FOR SIGNATURES & SIGN-OUT INFORMATION

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Participant Name: _____________________________________________________________________ 4-H Member Code of Conduct 2016-2017

Signature(s) (Both signatures are required for participants under 18 years old.)

I have read and understand the above “Code of Conduct” and will abide by the expectations described in the Code-of-Conduct. I understand that if I act inappropriately I will have to accept responsibility for my actions that may result in the consequences listed above.

Participant Signature Date

______________________________________________ ________________________

I have discussed and reviewed this Code of Conduct with my child. I understand that failure to abide by this Code of Conduct may result in the consequences listed above which includes no refund. In the event that this code is violated, I agree to come to the 4-H program/event to pick up my child at the request of the adult in charge of the 4-H program/event. I further understand that I refuse to pick up my child, am unavailable, or fail to make timely arrangements to retrieve my child, 4-H program/event staff may contact law enforcement or social services to provide necessary protection for a child in need of services. I acknowledge responsibility for all fees/charges that may result from said services.

Parent/Guardian’s Signature (for participant under 18 years old) Date

_______________________________________________ ________________________

Parental/ Guardian Release

Parent & Spouse Name (print here): ______________________________________________ Please list the individual(s) who have permission to pick up your child at the conclusion of this 4-H camp, event, or program in the spaces provided. Only those listed will be allowed to pickup your child.

Name(s): ____________________________________________________________________ Name(s): ____________________________________________________________________ Name(s): ____________________________________________________________________ Name(s): ____________________________________________________________________

Sign below at time of pick up (Receiving person must be pre-listed above):

Name (print): _____________________________________ Date/ Time __________________ Name (print): _____________________________________ Date/ Time __________________ Name (print): _____________________________________ Date/ Time __________________ Name (print): _____________________________________ Date/ Time __________________ Name (print): _____________________________________ Date/ Time __________________ Name (print): _____________________________________ Date/ Time __________________ Name (print): _____________________________________ Date/ Time __________________

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I hereby give my consent for the image and likeness of ___________________________________________ to be videotaped, audiotaped, or photographed for the following uses:• Educational/Instructional media • Recruitment/Outreach media• Development media • Newsworthy media documentation

I further authorize West Virginia University, WVU Extension Service, and/or West Virginia University Hospitals, Inc. and their component parts to use this electronic media and/or photographs in any manner-whole, or in part.

This waiver includes usage of this media in any way deemed appropriate, which may include electronic and photographical reproductions thereof for the production educational, instructional, promotional, or institutional advancement materials which support the educational and outreach activities of West Virginia University.

I hereby waive any right I may have to inspect or approve any use of this electronic media and/or photographs and I release West Virginia University and its component parts from all liability which could result from its use.

Participant’s Name ________________________________________________________________

Address ________________________________________________________________

________________________________________________________________

________________________________________________________________

Telephone Number ________________________________________________________________

Participant’s Signature ________________________________________________________________ (Required)

A parent or guardian must sign this form if the participant is a minor or if the participant is hindered by mental or physical challenges.

Parent/Guardian’s Name ________________________________________________________________

Parent/Guardian Signature ________________________________________________________________(Required)

Media Recording/Usage Release:WVU Extension Service County Offices

County Name: ________________________

Please return this media release to your WVU-ES county office. Find your WVU-ES county office address at www.wvu.edu/~exten/depts/county

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SPECIAL DIETARY NEEDS MEDICAL STATEMENT

Student's Name _________ DOB ____ School ________ County _____ WVEIS# __ _

* Does this patient have a disability that affects her/his diet? Yes or No Diagnosis ___________ _

*Does this patient have a non-disabling medical condition that affects his/her diet? Yes or No Diagnosis ___________ _

Did you refer this patient's family to receive diet education? Yes or No

If yes, to whom: DMD O RN ORD O CDE Name ___________ Phone _____ _

Diet Information sent to: DSchool Nurse

PLEASE MARK ONLY THE AREAS THAT APPLY:

O School Cook

Schools or sites may make substitutions for individuals with a non-disabling medical condition who are unable to consume the regular meal because of medical or other special dietary needs.

0 FOOD ALLERGIES:

.

.

D SUBSTITUTIONS MUST BE LISTED

.

.

.

0 SODIUM RESTRICTION (Specify Milligrams):

0 CARBOHYDRATE COUNTING (Specify Grams):

Breakfast Lunch

0 OTHER RESTRICTIONS:

.

.

.

OChild Nutrition Director OPrincipal DOther

0 CALORIC REQUIREMENTS: Please indicate the calories for each meal provided at school.

Daily Total Breakfast Lunch Snack

1200

1500

1800

2000

0 TEXTURE CONSISTENCIES for swallowing or chewing difficulties

SOLIDS LIQUIDS 0 Regular Chopped 0 Regular Consistency

0 Mechanical soft with ground meat 0 Honey Consistency

0 Mechanical soft with chopped meat 0 Nectar Consistency

0 Pureed 0 Pudding Consistency

0 NUTRITIONAL SUPPLEMENTS TO BE PROVIDED AT SCHOOL OR SITE Please specify amount and frequency of feeding ( for Breakfast and Lunch Only)

Oral Feedingsffube Feedings

*Additional Comments: ______________________________________ _

Disability

• If an individual with a disability requires a special diet, the United States Department of Agriculture requires a medical statement formcompleted and signed by a licensed physician: medical doctor (MD) or doctor of osteopathic medicine (DO). An updated medical statement must be provided annually or when any change is prescribed.

Non-Disabled Medical Condition

• If an individual has a medical condition requiring a special diet and is medically certified, the school food service may make substitutions to the regular diet on a case by case basis. A medical statement is required and must be completed by a medical doctor (MD), doctor of osteopathic medicine (DO), physician's assistant (PA), or nurse practitioner (ANP) and include substitutions to the regular menu. An updated medical statement must be provided annually or when any change is prescribed.

* See Attached Definitions.Sign Here:

Provider Name & Title (print) ParenUGuardian Name (print)

Signature, Credentials Date Signature Date

Provider Phone ParenUGuardian Phone

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Free and Reduced-Price Meals Household Application for 2016-2017 – West Virginia Dept. of Education USE BLACK OR DARK BLUE INK, PRINT NEATLY, COMPLETE ONE APPLCIATION PER HOUSEHOLD

1. Names of ALL Children in School, Center, or Camp

Last Name First Name MI

Date of Birth MM/DD/YY

Mark if Foster Grade School, Center, or Camp

/ /

/ /

/ /

/ /

/ /

2. SNAP/TANF NUMBER SNAP TANFIf any member of your household receives SNAP or TANF, indicate which program and provide the 10-digit case #

(If any, SKIP TO PART 5)

3. HOMELESS, MIGRANT, RUNAWAY Homeless Migrant Runaway

If the child you are applying for is homeless, migrant, or runaway, check the appropriate box and call your county contact at .

4. HOUSEHOLD MEMBERS AND GROSS INCOME FROM LAST MONTHList each person in the household. For each person who receives income, write the amount received and fill in how often it is received.

Name (Last, First) List everyone in the Household. Attach a separate sheet if needed.

Monthly Earnings from Work

(Before Deductions)

Monthly Welfare, Child Support,

Alimony

Monthly Payments from

Pensions, Retirement, Social Security

Other Monthly Income

Check if no

Income

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

Total Number of Persons in Household Total Monthly Income Before Deductions $

5. Signature and Social Security Number (Adult must sign.)An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last 4 digits of his or herSocial Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page)I certify (promise) that all information on this application is true and that all income is reported. I understand that the school system may get federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my child(ren) may lose meal benefits, and I may be prosecuted. Today’s Date Last 4 Digits of Social Security Number

I do not have a Social Security Number Signature

Printed Name Home Phone Number Work Phone Number

Mailing Address City State ZIP Code

6. Children’s Race and Ethnicity - (You do not have to complete this part to receive free and reduced price meals.)Mark one or more racial identities from this group:_____ Asian _____ American Indian or Alaska Native _____ White _____ Black or African American _____ Native Hawaiian or Other Pacific Islander And mark one ethnic identity from this group: _____ Hispanic or Latino _____ Not Hispanic or Latino

7. Other Benefits - (You do not have to complete this part to receive free and reduced price meals.)_____ Yes, school officials may use the information provided on this application to determine my child(ren)’s eligibility for free textbooks,

workbooks, and other school supplies.

Do not fill out this part. This is for sponsor’s use only. Annual Income Conversion: Weekly X 52, Every 2 Weeks X 26, Twice A Month X 24, Monthly X 12

Categorically Eligibility: -or- Income Eligibility: Free Meals

Reduced MealsDenied: Reason:

Signature/Stamp of Approving Official _____________________________________Date Approved ____________ Date Withdrawn ______

Verification: Confirming Official’s Signature Date

Follow-up Official’s Signature Date

WVDE-ADM-121 “Continue on Back” FY2017

* * * * *

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Free and Reduced-Price Meals Household Application for 2016-2017 – West Virginia Dept. of Education USE BLACK OR DARK BLUE INK, PRINT NEATLY, COMPLETE ONE APPLCIATION PER HOUSEHOLD

8: Free and Low-Cost Health Care

If your children get free or reduced price school meals, they may also be able to get free or low-cost insurance through Medicaid or the West Virginia Children’s Health Insurance Program (WVCHIP). Children with health insurance are more likely to get regular health care and are less likely to miss school because of sickness.

If you would like information about WVCHIP or Medicaid, please call toll-free anytime at 1-877-982-2447 or visit www.chip.wv.gov You may also apply online at www.wvinroads.org.

Your children may qualify for free or

reduced price meals if your

household income does not

exceed the limits on this chart.

Privacy Act Statement: This explains how we will use the information you give us.

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

Non-discrimination Statement:

In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating based on race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs.)

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the responsible State or local Agency that administers the program or the USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a complaint alleging discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; fax: (202) 690-7442; or email: program.intake@usda.gov.

This institution is an equal opportunity provider.

WVDE-ADM-121 FY20175/2016

FEDERAL INCOME CHART For School Year July 1, 2016 – June 30, 2017

Household size Yearly Monthly Twice Per Month

Every Two Weeks

Weekly

1 $21,978 $1,832 916 846 4232 29,637 2,470 1,235 1,140 5703 37,296 3,108 1,554 1,435 7184 44,955 3,747 1,874 1,730 8655 52,614 4,385 2,193 2,024 1,0126 60,273 5,023 2,512 2,319 1,1607 67,951 5,663 2,832 2,614 1,3078 75,647 6,304 3,152 2,910 1,455

Each additional person: 7,696 642 321 296 148

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Program Year 2016-2017 West Virginia Department of Education

FREE AND REDUCED PRICE SCHOOL MEAL FAMILY APPLICATION

INSTRUCTIONS FOR APPLYING

If you are applying for a FOSTER CHILD, follow these instructions: If all children in the household are foster children: Part 1: List all foster children, date of birth, grade and school, center, or camp. Part 2: Skip this part. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. The last four digits of a Social Security Number are not necessary. Part 6: Answer this question if you choose.

If some children in the household are foster children: Part 1: List all children in the household (including foster children), date of birth, mark box if foster child, grade, and school, center, or camp. Part 2: If the household does not have a case number, skip this part. Part 3: If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call the contact number listed. Part 4: Follow these instructions to report total household income from last month.

Column 1–Name: List all household members. Column 2–Last month’s income: List the types of income your household received last month. Employment Income: List the gross income each person earned last month. It is not the same as take home pay. Gross income is the amount earned before taxes and deductions. It should be listed on your pay stub, or your boss can tell you. Other Income: List the total amount each person received last month from all other sources. Include welfare, child support, alimony, pensions, retirement, Social Security, Worker’s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, withdrawals from savings, and ANY OTHER INCOME. Report net income for self-owned business, farm, or rental income. Last Column–Check if no income: If the person does not have any income, check the box.

Part 5: An adult household member must sign the form and list the last 4 digits of his or her Social Security Number, or mark the box if he or she doesn’t have one.

Part 6: Answer this question if you choose. Part 7: Answer this question if you choose. Part 8: (Found on back of application.) Call number listed to request WVCHIP or Medicaid information.

WVDE-ADM-121 Letter to Households 06/2015

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:Part 1: List each child’s name, date of birth, grade and school, center, or camp. Part 2: Skip this part. Part 3: Check a box only if it applies. Part 4: Follow these instructions to report total household income from last month.

Column 1–Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children. Attach another sheet of paper with household members if required. Column 2–Last month’s income: List the types of income your household received last month. Employment Income: List the gross income each person earned last month. It is not the same as take home pay. Gross income is the amount earned before taxes and deductions. It should be listed on your pay stub, or your boss can tell you. Other Income: List the total amount each person received last month from all other sources. Include welfare, child support, alimony, pensions, retirement, Social Security, Worker’s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, withdrawals from savings, and ANY OTHER INCOME. Report net income for self-owned business, farm, or rental income. Last Column–Check if no income: If the person does not have any income, check the box.

Part 5: An adult household member must sign the form and list the last 4 digits of his or her Social Security Number, or mark the box if he or she doesn’t have one.

Part 6: Answer this question if you choose. Part 7: Answer this question if you choose. Part 8: (Found on back of application.) Call number listed to request WVCHIP or Medicaid information.

If you are applying for a child who is HOMELESS, MIGRANT, or a RUNAWAY, follow these instructions: check the appropriate boxand call your county contact at the phone number listed in Part 3 of the application. Fill out the rest of the application by following instructions for ALL OTHER HOUSEHOLDS.

If your household gets FOOD STAMPS OR TANF, follow these instructions:Part 1: List child(ren)’s name, date of birth, grade, and school, center, or camp. Part 2: Check the appropriate box and list the 10-digit Food Stamp or TANF case number. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. A Social Security Number is not necessary. Part 6: Answer this question if you choose. Part 7: Answer this question if you choose. Part 8: (Found on back of application.) Call number listed to request WVCHIP or Medicaid information.

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Camp Payment and Payment Form

Camp Payment– make checks payable to Cabell County 4-H Foundation. See the next page for more information. Please select ONLY ONE option.

Early Bird Registration – Before April 28, 2017 Older or Younger Early Bird ___ Full Payment - $100 ___ Deposit (with remainder due May 15) - $25 ___ 4-H Club is paying ___ Free and Reduced Lunch Eligible - Full Payment - $55 ___ Free and Reduced Lunch Eligible - Deposit (with remainder due May 15) - $25 ___ Free and Reduced Lunch Eligible - 4-H Club is paying

Cloverbud STEM Camp Early Bird ___ Full Payment - $40 ___ Deposit (with remainder due May 15) - $25 ___ 4-H Club is paying

Regular Rate Registration – Between April 29 and May 15, 2017 Older or Younger Regular Rate ___ Full Payment - $125 ___ Deposit (with remainder due May 15) - $25 ___ 4-H Club is paying ___ Free and Reduced Lunch Eligible - Full Payment - $80 ___ Free and Reduced Lunch Eligible - Deposit (with remainder due May 15) - $25 ___ Free and Reduced Lunch Eligible - 4-H Club is paying

Cloverbud STEM Camp Regular Rate ___ Full Payment - $50 ___ Deposit (with remainder due May 15) - $25 ___ 4-H Club is paying

Camp Registration Payment Today: $________

Do you want a camp t-shirt? ___ Yes (Add $5 to Camp Payment – Due upon receipt of registration form) ___ No

T-shirt fee: $________

Total Camp Registration Payment Today: $________

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4-H OLDER Camp Class Selection

FULL NAME Rank your TOP 9 classes from the following list of classes with ‘1’ being your first choice and ‘9’ being your last choice. Classes will be assigned on a first-come, first-served basis.

Rank Class Class Description Instructor 4-H Camp Songs Learn traditional camp songs that are essential for 4-H

Camp spirit Caleb Runyon

4-H Sewing Class Learn the basics of sewing and make a 4-H Camp souvenir Della Adkins Archery Learn the parts of a bow and arrow and how to safely

shoot them Extension Camping Instructor

Arts and Crafts Create art that you can take home! Includes jewelry, melted crayon art on canvas, and more!

Camp Counselor

Camp Newspaper

Interview campers, take pictures, and created interesting stories to share in the 4-H Camp Newspaper.

Jamie Butcher

Camp Tasting Party

Learn to prepare delicious food in the 4-H Camp kitchen. Camp Counselor

Charting Must have been working on the Charting project throughout the year.

Extension Camping Instructor

DDR Do you have the moves? Learn to play Dance Dance Revolution and compete against other campers.

Camp Counselor

Fishing Learn how to fish and go fishing at camp! Rod Ashworth Hiking and Geocaching

Explore the outdoors around camp and learn how to use GPS units for geocaching. Must bring tennis shoes.

Camp Counselor

Jewelry Create jewelry that you can take home as camp souvenirs Glendoria Armentrout Outdoor Cooking Learn to create tasty snacks over a campfire. Camp Counselor Outdoor Recreation

Play great group games outdoors with your new camp friends. Must bring tennis shoes.

Camp Counselor

Party Planning and Decorating

Prepare decorations for the Carnival and learn party planning skills you can take home.

Zeb Nottingham

Paper Maché Pig Create a painted pig from paper maché that you can take home as a souvenir (this can get messy).

Camp Counselor

Photography Take action photographs of campers during camp to share in the camp slide show.

Leslie Lehman

Plaster Crafts Make camp souvenirs out of plaster cloth – this will be messy, so bring an apron!

Camp Counselor

Pinewood Derby Make a pinewood derby car Rod Ashworth STEM Do exciting science experiments and learn science magic

tricks to impress your friends! Camp Counselor

Tie Dye Create colorful camp souvenirs. Must bring 2 items to dye. Faith Adkins Tribal Leadership Learn how to be a great 4-H camp chief or sag. Extension Camping

Instructor Yoga Relax as you learn how to be healthy and calm in this class. Camp Counselor Zumba Be healthy and have fun doing it with this fun class. Chiauna Spaulding

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Transportation Permission FormPlease complete

As parent or guardian of (Child's Name),

I hereby give my permission for my child to participate in the following WVUESActivity/Event:Be transported to and from at Guyan Estates Swim Club, Inc., for swimming as part of Cabell County 4-H Older Camp (June 5-9, 2017)

My child has permission to ride in the authorized vehicle being used to transport theyouth to this activity. (This includes a rental vehicle, school bus, charter bus or a WVUvehicle or county owned vehicle. This does not include personal vehicles). My childmay travel from the county to the activity and make incidental stops along the way asthe vetted volunteers may deem necessary.

I understand and acknowledge that participation in the activities involves inherent risksof injury to my child including risks associated with transportation by motor vehicle. Irelease West Virginia University Extension Service, their affiliates from liability for injuryor damages which may result from my child's participation in this field trip.

A WVUES vetted volunteer or WVUES employee age 21 or over will be driving theauthorized vehicle or an employee of either the school system (school bus) or CharterCompany. The driver will be accompanied by another vetted volunteer or staff memberover the age of 18. If a school bus or charter bus is used, two WVUES vettedvolunteers will accompany the trip and will be present at all times.

My child and I agree that he/she will abide by the Expectations and Code of Conductwhile being transported to and from this WVUES activity/ event, and during the activity.

Signature of Parent or Guardian:

Date:

For WVUES Faculty Member Use Only:

This event will begin on June 5, 2017 at 9:00 am and will Date Time

conclude on June 9, 2017 at 12:00 pm .Date Time

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18

19

2016-17 West Virginia 4-H Member Enrollment

PROFILE INFORMATION

Club Name: _______________________________________________________________________________________________________________

Family Name:__________________________________________________________ Family Phone: _____________________________________

Email: ____________________________________________________________________________________________________________________

First Name:_______________________________________________________ Middle Name: __________________________________________

Last Name:_______________________________________________ Suffix: __________ Preferred Name: _______________________________

Mailing Address:______________________________________________ Mailing Address 2: ___________________________________________

City, State: _______________________________________________________________________________ Zip: _____________________________

Date of Birth: _________ /_________ /_________ Gender: q Male q Female Years in 4-H: _________________________________

Primary Phone: ___________________________________________

Cell Phone: _______________________________________________

PARENT 1:

First Name:_________________________________________________ Last Name: ___________________________________________________

Cell Phone: ______________________________________ Work Phone: ____________________________________Work Extension: _________

PARENT 2:

First Name:_________________________________________________ Last Name: ___________________________________________________

Cell Phone: ______________________________________ Work Phone: ____________________________________Work Extension: _________

Mailing Address:______________________________________________ Mailing Address 2: ___________________________________________

City, State: _______________________________________________________________________________ Zip: _____________________________

Home Phone: _________________________________________________ Email: _____________________________________________________

SECOND HOUSEHOLD:

Send Correspondence: q Yes q No Correspondence Preference: q Email q Mail

Family Last Name: ___________________________________________ Family First Name: ___________________________________________

Mailing Address:______________________________________________ Mailing Address 2: ___________________________________________

City, State: _______________________________________________________________________________ Zip: _____________________________

Primary Phone: _______________________________________________ Email: ______________________________________________________

EMERGENCY CONTACT:

Name: ____________________________________________________________________________________________________________________

Phone: ________________________________________________________ Cell Phone: _______________________________________________

Email: ________________________________________________________ Contact Relationship: _______________________________________

4-H County: ______________________________________________________________________________________________________________

Correspondence Preference: q Email q MailDo you wish to receive notices via text message: q Yes q No Provider:______________________________________________________

Continued

MM DD YYYY

20

West Virginia University Extension Service 4-H Youth Development

VOLUNTEER Did you serve in a leadership capacity in 4-H? q Yes q No (Example for youth: Junior Leader, Club Officer, etc. Examples for Adult: Chaperone, Community Club Leader, Project Leader, etc.)

Are you a volunteer? q Yes q No

ETHNICITY Are you Hispanic or Latino ethnicity? q Yes q No

RACE Check all races that apply to you. If you selected “Not Hispanic,” you must select at least one option.

q White q Black q Asian

q American Indian or Alaskan Native

q Native Hawaiian and Pacific Islander

4-H MEMBER CODE OF CONDUCT1. The purpose of the WVU Extension Service 4-H Program is to provide positive youth development. We believe in creating

a safe learning environment that encourages four-fold youth development (i.e., Head, Heart, Hands and Health). All 4-H membersparticipating in or attending club, county, regional, state and national programs, activities, events, shows and contests sponsoredby the WVU Extension Service or representing 4-H at non-4-H events are required to conduct themselves according to the currentWest Virginia 4-H Member Code of Conduct and future modifications or amendments to the West Virginia 4-H Member Codeof Conduct.

2. I am aware that my actions and decisions affect me and others. I acknowledge that I have been given a copy of the West Virginia4-H Member Code of Conduct. I agree to conduct myself in accordance with the West Virginia 4-H Member Code of Conductat all times. I understand that my failure to do so may result in the loss of privileges during 4-H programs, including involvementin future 4-H events or programs. My signature below demonstrates my agreement to abide by the West Virginia 4-H MemberCode of Conduct, as well as any code of conduct established for a specific 4-H event or program I attend.

_________________________________________________________________________________________ ______________________________

I have read, reviewed and discussed the current West Virginia 4-H Member Code of Conduct with my child. I understand that my child will be expected to conduct himself/herself in accordance with the current West Virginia 4-H Member Code of Conduct and any future modifications or amendments at all times, and that failure to do so may result in the consequences stated in paragraph 2 above. I also understand that coordinators of 4-H programs, such as camps, overnight events and livestock shows, often establish specific expectations, guidelines and consequences, and should my child choose to participate in these events, he/she will be expected to review the rules and expectations for each event and follow them accordingly.

_________________________________________________________________________________________ ______________________________Signature of Parent or Legal Guardian – not required if member is 18 or older Date

Signature of 4-H Member Date

RESIDENCE q Farm q Town under 10,000 residents and rural non-farm

q Town of 10,000 to 50,000 residents and its suburbs

q Suburb city more than 50,000 residents

q Central city more than 50,000 residents

SCHOOL INFORMATION School County: _____________________________________________

School District: _____________________________________________

School Name: ______________________________________________

School Type: (i.e., home school, private school, public school) _____

___________________________________________________________

___________________________________________________________

School Grade: ______________________________________________

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ANIMAL SCIENCE(For beef, dairy, horse, sheep, swine, poultry, dog, rabbit, goat, pets, and cat projects, you must also select an animal record guide.)Livestock record guides are based on 4-H member’s age as of Jan. 1 of the 4-H year. Please check:

q Beginner (age 8-10)q Intermediate (age 11-13)q Advanced (age 14-20)

10310 q V et Science I – The Normal Animal10320 q V et Science II – Animal Disease10330 q Vet Science III – Animal Health1041 q Bite Into Beef (Beef 1) – Year ___1042 q Here’s the Beef (Beef 2) – Year ___1043 q Leading the Charge (Beef 3) –

Year ___10440 q 4-H Beef Heifer/Cow Record Guide10450 q 4-H Feeder Calf Record Guide 10460 q 4-H Market Beef Record Guide1051 q Cowabunga! (Dairy 1) – Year ___1052 q Mooving Ahead (Dairy 2) –

Year ___1053 q Rising to the Top (Dairy 3) –

Year ___ 10540 q 4-H Dairy Record Guide_____ (List number of animal records needed.)1061 q Giddy Up and Go (Horse 1) –

Year ___1062 q Head, Heart and Hooves (Horse 2) –

Year ___1063 q Stable Relationships (Horse 3) –

Year ___

1064 q Riding the Range (Horse 4) – Year ___

1065 q Jumping to New Heights (Horse 5) – Year ___

10660 q 4-H Horse Record Guide1071 q Lambs, Rams and You (Sheep 1) –

Year ___1072 q Shear Delight (Sheep 2) –

Year ___1073 q Leading the Flock (Sheep 3) –

Year ___10740 q 4-H Breeding Sheep Record Guide10750 q 4-H Market Lamb Record Guide1081 q The Incredible Pig (Swine 1) –

Year ___1082 q Putting the Oink in Pig (Swine 2) –

Year ___1083 q Going Whole Hog (Swine 3) –

Year ___1084 q 4-H Purebred Swine Record Guide10910 q 4-H Market Hog Record Guide1101 q Scratching the Surface (Poultry 1) –

Year ___1102 q Testing Your Wings (Poultry 2) –

Year ___1103 q Flocking Together (Poultry 3) –

Year ___11040 q 4-H Breeding Poultry Record Guide11050 q 4-H Market Poultry Record Guide1111 q Wiggles and Wags (Dog 1) –

Year ___1112 q Canine Connection (Dog 2) –

Year ___1113 q Leading the Pack (Dog 3) –Year ___11140 q 4-H Dog Record Guide

1121 q What’s Hoppening? (Rabbit 1) – Year ___

1122 q Making Tracks (Rabbit 2) – Year ___1123 q All Ears (Rabbit 3) – Year ___11240 q 4-H Market Rabbit Record Guide11250 q 4-H Breeding Rabbit Record Guide1131 q Getting Your Goat (Dairy Goat 1) –

Year ___1132 q Stepping Out (Dairy Goat 2) –

Year ___1133 q Showing the Way (Dairy Goat 3) –

Year ___1134 q 4-H Dairy Goat Record Guide 1135 q Just Browsing (Meat Goat 1) –

Year ___1136 q Get Growing with Meat Goats –

(Meat Goat 2) – Year ___1137 q Meating the Future (Meat Goat 3) –

Year ___11380 q 4-H Breeding Meat Goat

Record Guide11390 q 4-H Market Goat Record Guide1141 q Pet Pals (Pets 1) – Year ___1142 q Scurrying Ahead (Pets 2) – Year ___1143 q Scaling the Heights (Pets 3) –

Year ___11440 q 4-H Pets Record Guide (List kind of pet _________________________ )1151 q Purr-fect Pals (Cat 1) – Year ___1152 q Climbing Up! (Cat 2) – Year ___1153 q Leaping Forward (Cat 3) –

Year ___11540 q 4-H Cat Record Guide11990 q Self-Determined Animal Science

West Virginia University Extension Service 4-H Youth Development

4-H PROJECTS:Put an (X) in the box for the project(s) you plan to carry this year.

Club Name: ________________________________________________________________________________________________________________________

WVU EXTENSION SERVICE MEDIA RELEASE

q I do not consent to the publication of the image and likeness of the above named participant to be videotaped, audio taped or photographed.

q I hereby give my consent for the image and likeness of the above named participant to be videotaped, audio taped or photographedfor the following uses:• Educational/Instructional media • Recruitment/Outreach media • Development media • Newsworthy media documentation

I further authorize West Virginia University, WVU Extension Service and/or West Virginia University Hospitals, Inc. and their component parts to use this electronic media and/or photographs in any manner – whole or in part.

This waiver includes usage of this media in any way deemed appropriate, which may include electronic and photographical reproductions thereof for the production of educational, instructional, promotional or institutional advancement materials, which support the educational and outreach activities of West Virginia University.

I hereby waive any right I may have to inspect or approve any use of this electronic media and/or photographs, and I release West Virginia University and its component parts from all liability which could result from its use.

_________________________________________________________________________________________ _______________________________________

Parent or Guardian Name (print here): ______________________________________________________________________________. I give permission to the following individual(s) to pick up my child at the conclusion of this 4-H event or program:

Name(s):_______________________________________, _______________________________________, __________________________________________

Signature of Parent or Legal Guardian (Required even if participant is 18 or older.) Date

22

4-H Youth Development

Programs and activities offered by the West Virginia University Extension Service are available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political beliefs, sexual orientation, national origin, and marital or family status. Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Director, Cooperative Extension Service, West Virginia University.

Background and National Sexual Predator Website Checks Consent Form

To participate as an adult in WVU Extension Service 4-H programs, either as a 4-H member or volunteer, you must be background checked once every three years and checked against the National Sexual Predator Website register yearly. I, _________________________________ (first, middle, and last name) authorize WVU Extension Service to initiate a background check through TalentWise/Sterling One and to perform a search on the National Sexual Predator Website. Legal Name (first, middle, last name printed): E-mail Address (REQUIRED): Signature: Date:

23

4-H Youth Development

Programs and activities offered by the West Virginia University Extension Service are available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political beliefs, sexual orientation, national origin, and marital or family status. Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Director, Cooperative Extension Service, West Virginia University.

WVU Children on Campus Training Procedures

To participate as an adult in WVU Extension Service 4-H programs, either as a 4-H member or volunteer, you must complete the WVU Children on Campus training yearly and submit your Certificate of Completion to the Cabell County Extension Office. Instructions

1. Go to training website: https://employmentservices.hr.wvu.edu/r/download/191248 2. Read the Policy Training Workbook. 3. Select the training quiz link at the end of the workbook. 4. Provide your name, e-mail address, and department to initiate the training quiz. Your

Department is Extension Service. 5. Print or save your certificate. 6. Mail your printed certificate to:

Cabell County Extension Office Attn: Autumn Starcher 2726 Howells Mill Road PO Box 219 Ona, WV 25545

Or e-mail to: Autumn.Starcher@mail.wvu.edu Please contact me at 304-743-7151 if you have any questions. Yours in 4-H,

Autumn N. Starcher, Ph.D. Extension Agent, 4-H Youth Development

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4-H Youth Development

Programs and activities offered by the West Virginia University Extension Service are available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political beliefs, sexual orientation, national origin, and marital or family status. Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Director, Cooperative Extension Service, West Virginia University.

Title IX Training

The mandatory Title IX training for 4-H volunteers and 4-H’ers 18 years of age and older will be offered on the following dates. These trainings will be available at the locations specified in the table as well as through live streaming at the Cabell County Extension Office. This training is required once every three years for 4-H volunteers and 4-H’ers 18 years of age and older.

Date Time Location Live Stream

March 13 10am – 12pm Assembly Hall—Jackson’s Mill Cabell County Extension Office

March 24 8pm – 10pm West Virginia Building—Jackson’s Mill Cabell County

Extension Office

April 21 7pm – 9pm Gilmer County Cabell County

Extension Office

April 24 7pm – 9pm Pumpkin Park – 4-H/FFA Building N/A

May 20 10am – 12pm Berkeley County—Camp Frame Cabell County

Extension Office

May 22 1pm – 3pm Assembly Hall—Jackson’s Mill Cabell County

Extension Office

June 3 9am – 11am Jackson’s Mill—Fire Academy Cabell County

Extension Office

June 3 1pm – 3pm Beckley—Carter Hall Conference Room Cabell County

Extension Office

Please contact Autumn Starcher by email at autumn.starcher@mail.wvu.edu or by telephone at 304-743-7151 if you have any questions or would like to request additional training dates.

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