JDC 4-H Ski Day

This event is open to all 4-Hers and their immediate family members AND 1 guest per 4-H member. This will take place the the

Chestnut Mountain Ski Resort- Galena, IL.All forms and money must be turned in to the Extension Office, located at 204 Vine

St., PO Box 600, Elizabeth, IL 61028 by the deadline. No Exceptions!

SUNDAY, JANUARY 19, 2020

DEADLINE IS JANUARY 14 @ 4:30 PMCheck-in is from 12:30-1:30 pm

*Bad weather date: January 26

*Medical Release Form *Currently enrolled in 4-H

*Liability waiver- if not on file*Registration Form

*Make checks payable to: University of IL Extension

Find all the forms on our website @go.illinois.edu/jsw

University of Illinois Extension provides educational programs and research based information to help Illinois residents improve their quality of life, develop skills and solve problems. If you need areasonable accommodation to participate in this program, please call the U of I Extension office. University of Illinois Extension provides equal opportunities in programs and employment.

University of Illinois College of Agricultural, Consumer and Environmental Sciences – United States Department of Agriculture – Local Extension Councils Cooperating

If you need a reasonable accommodation to participate in this program, please contact the Extension Office at 815-858-2273. Early requests are strongly encouraged to allow sufficienttime for meeting your access needs.

*Code of Conduct

Forms must be completed by all participants and include:

JO DAVIESS COUNTY 4-H SKI DAY WHO: All 4-H Members, All 4-H Families, and ONE Guest per 4-H Member WHEN: Sunday, January 19, 2020 *bad weather date in January 26 WHERE: Chestnut Mountain Ski Resort- Check In between 12:30-1:30 pm

Meet at the Group Window area to receive tickets from Federation Officer/Ext. Staff

Package Cost to 4-H Member or 4-H Family Cost to Guest of 4-H Member A: Lift Ticket, Ski or Board Rental &

Free Group Lesson $20/person $40/person

B: Lift Ticket Only $15/person $30/person

Please make checks payable to: University of IL Extension

SKI TRIP PARTICIPATION REGISTRATION/PERMISSION FORM

Return by: January 14, 2020 by 4:30 pm

Participant Name 4-H Family Guest Package (Please Print Legibly) (Please state 4-H Club) (Please state guest of (Choose A, B

which 4-H member) from list above)

Phone number: _____________________________ Email: _____________________________ (will be used in case of bad weather) (will be used in case of bad weather)

Please Note: A completed and signed medical release (both sides) MUST accompany this form in order to be registered for this event! You must also complete the liability waiver IF you have not done so. Every person attending (including guests) must have completed both forms. *Money is due at registration… your registration will not be valid if sent without payment. Please note: non 4-H members are NOT covered by our insurance.

I give permission for my son/daughter to participate in the Jo Daviess County 4-H Ski Day at Chestnut Mountain Resort on January 19, 2020.

Parent/Guardian signature

Amount enclosed

Return to: Jo Daviess County Extension 204 Vine St., PO Box 600

Elizabeth, IL 61028

Jo Daviess County 4-H | 204 Vine St., PO Box 600 | Elizabeth, IL 61036 | 815-858-2273 | go.illinois.edu/jswCOLLEGE OF AGRICULTURAL, CONSUMER & ENVIRONMENTAL SCIENCES University of Illinois | U.S. Department of Agriculture | Local Extension

Councils Cooperating University of Illinois Extension provides equal opportunities in programs and employment.

Extension Participant/Volunteer AGREEMENT TO ASSUME RISKS AND FULLY RELEASE ALL CLAIMS

Extension Volunteer Agreement to Assume Risk/Approved for legal form by OUC/LMP/092018

Risks of Extension Activities. I understand that my participation in University of Illinois Extension activities can present risks of physical injury (including death or disability) to me and damage to my personal property. The University of Illinois does not guarantee my personal health or safety or protect me against property loss. Physical injury to me or property damage may result from known or unexpected risks arising from things such as: use of equipment, materials, or facilities; environmental conditions, including poisonous plants, insects, and extreme heat or cold and other weather-related hazards; natural disasters; water activities; transportation; actions of others; animal behaviors; unavailability of immediate or adequate emergency care; infectious diseases; and slips and falls.

Risks of 4-H Equine Activities. Equine (horse, pony, mule, donkey, or hinny) activities present dangerous risks of injury and harm, regardless of the safety measures taken. If a horse or other equine animal is frightened or provoked, I understand that it might ignore its training and act according to its natural survival instincts, which may include actions such as unexpected change of directions or speed; running; sudden movement or stopping; shifting weight; bucking; rearing; kicking; and biting. I understand that UNDER THE ILLINOIS EQUINE ACTIVITY LIABILITY ACT, EACH PARTICIPANT WHO ENGAGES IN AN EQUINE ACTIVITY EXPRESSLY ASSUMES THE RISK OF ENGAGING IN AND LEGAL RESPONSIBILITY FOR THE INJURY, LOSS, OR DAMAGE TO PERSON OR PROPERTY RESULTING FROM THE RISK OF EQUINE ACTIVITIES. Risk of equine activities means dangers including but not limited to: (1) propensity of an equine to behave in ways that may result in injury, harm or death to persons on or around them; (2) unpredictability of an equine’s reaction to sounds, sudden movement, and unfamiliar objects, persons, other animals or other things; (3) certain hazards such as surface and subsurface conditions; (4) collisions with other equines or objects; and (5) the potential of a participant to act in a negligent manner that may contribute to injury, such as failing to maintain control over the animal or not acting within his or her ability. Risks of 4-H Shooting Sports Activities: Shooting sports involve the use of firearms, live ammunition, or archery equipment. I understand that there are inherent dangers associated with my participation in shooting sports, including observation. The potential dangers include, among other things, gunshot or archery wounds that can result in paralysis or loss of vision, limb, or life.

Assumption of Risks and Release of Claims: In consideration for allowing me to participate in Extension activities, I voluntarily assume all risk of injury and loss that I may sustain or suffer in connection with my participation in the activities described in this Agreement, and I forever and fully release, waive, and discharge all claims, demands, actions, and causes of action, known or unknown, that I have or that may accrue to me in the future (“Claims”) against the Board of Trustees of the University of Illinois, its officers, employees, agents, and volunteers (individually a “Releasee”) for personal injuries (including death), damage to property, and all liabilities, losses, costs, and expenses (including attorney fees) arising out of or resulting from my participation in Extension activities, including all Claims arising, in whole or in part, from the negligence of any Releasee. This Agreement is binding on my heirs, assigns, and representatives.

Effective Date: This Agreement is effective on the date signed by me (“Effective Date”) and replaces any similar agreements previously signed by me as to Extension activities that occur on or after the Effective Date. PARTICIPANT/VOLUNTEER SIGNATURE: DATE:

PRINTED NAME: BIRTHDATE:

HOME STREET ADDRESS: CITY: STATE: ZIP: PHONE: EMAIL: IF PARTICIPANT/VOLUNTEER IS UNDER 18 YEARS OLD: PARENT/LEGAL GUARDIAN SIGNATURE: DATE: PRINTED NAME: PHONE/EMAIL:

University of Illinois Extension Code of Conduct for 4-H Events & Activities

ALL participants in events and/or activities planned, conducted, and supervised by the University of Illinois Extension and 4-H, are responsible for their conduct to U of I Extension personnel and/or volunteers supervising the events. This responsibility is necessary for the health, safety, and welfare of the participants, and will be rigidly adhered to and uniformly enforced.

The following conduct is not allowed while participating in any 4-H event or activity and is subject to disciplinary action:

Category 1

a) Possession, use or distribution of alcohol and other drugs, including tobaccoproducts*

b) Theft or destruction of public or private propertyc) Involvement in sexual misconduct or harassmentd) Possession or use of dangerous weapons or materials (including fireworks)e) Fighting or other acts of violence that endanger the safety of the participant or

others

Category 2

a) Willfully breaking curfewb) Unauthorized use of vehiclesc) Leaving the site of the eventd) Participation in gamblinge) Absence from the planned programf) Intentionally interfering with or disrupting the eventg) Use of profane or abusive languageh) Disregard for public or personal propertyi) Public displays of affection or inappropriate actionsj) Failure to comply with direction of Extension personnel, including designated

adults acting within their duties and guidelines

* Prescription drugs must be listed on an Emergency Medical Information form.

Consequences:

The University of Illinois Extension reserves the right to restrict participation in future activities for those individuals who have been removed from an activity for behavior, as outlined in Category 1 or Category 2.

In all cases, the participant will be responsible for restitution of any damages incurred by his/her actions.

Event/Coordinator Copy

Category 1:

1. When notified of any of the actions listed under Category 1, the adult in charge, willascertain the relevant facts, and with concurrence from the U of I Extension staff, willnotify the affected participant of the action and any supporting evidence. The participantwill be allowed an opportunity to answer the allegations and, if necessary, lawenforcement officials will be notified. While facts are being verified, the participant willbe removed from the 4-H activity/event and be under direct supervision of an adultchaperon.

2. The parent of guardian will be notified of the actions of the participant, and upon findingthe allegations to be true, must immediately remove the participant from the activity atthe parent’s or guardian’s expense.

3. Documentation must be completed on an “Incident Report Form.”

Category 2:

1. When notified of any of the actions listed under Category 2, the adult in charge, willascertain the relevant facts, and, with concurrence from the U of I Extension staff, willnotify the participant of the action and any supporting evidence. The participant will beallowed an opportunity to answer the allegations and, if necessary, law enforcementofficials will be notified. While facts are being verified, the participant will be removedfrom the 4-H activity/event and be under direct supervision of an adult chaperon.

2. The parent or guardian of the participants who violate curfew, use vehicles withoutauthorization or leave the site of the event (as outlined in Category 2, letters a, b, c) willbe notified of the actions by the participant. The parent or guardian must immediatelyremove the participant from the activity, at the parent’s or guardian’s expense.Participants who willfully disobey conduct as described Category 2, letters d-j, willreceive a verbal and written warning (initialed by the adult and the participant). Uponreceiving a second warning, the parent or guardian will be notified of the behavior andmust make arrangements for removal of the participant from the activity, at the parent’sor guardian’s expense.

“We understand and accept the responsibility for following the “Code of Conduct” for this 4-H event or activity. We further understand that failure to do so will result in disciplinary action as outlined above and forfeiture of any participant’s fees.”

Signature of Participant Date Signature of Parent/Guardian Date

Note: Failure to have two bonafide signatures above shall be sufficient reason to disqualify the participant from this activity or event.

Two copies of this form must be signed. One copy shall be returned to the Event Coordinator and one copy shall be kept by the parent/guardian.

Return this form by December 15. Event/Coordinator Copy

ILLINOIS 4-H EMERGENCY MEDICAL FORM

PARTICIPANT NAME:_________________________________________________________________

Address:___________________________________________________________________________________________

CityStreet State/Zip Code

Age:________________ Sex: F M Birth Date:______ /______ /_________

PARENT / GUARDIAN / OTHER EMERGENCY CONTACT

Name:______________________________________________________________________________________________ Relationship

Home Phone: (______)___________ -______________ Work Phone: (______)___________ -______________

Cell Phone: (______)___________ -______________

Address:___________________________________________________________________________________________ Street City State/Zip Code

1. Nervous or Mental (epilepsy, emotional stress, convul-

sions)

2. Lung Disease (asthma, persistent cough, tuberculosis)

3. Disease of Heart or Blood Vessels, Increased or Abnor-

mal Blood Pressure

4. Pain in Chest or Shortness of Breath (heart murmur,

rheumatic fever)

5. Stomach or Intestinal Trouble (ulcers, gall bladder or

liver disorder, jaundice, hernia, colitis)

6. Arthritis, Diabetes, Kidney or Bladder Disease

7. Hay Fever or Allergies

8. Allergy to Medicines (including penicillin, tetanus)

9. Impaired Sight or Hearing, Chronic Ear Infections

10. Recent Surgical Operations, Accidents or Injuries

11. Any Infectious Disease

12. Skin Disease

13. Allergy to Foods

14. Significant Orthopedic and/or Neuromuscular Impair-

ment (e.g. loss of limb, spinal cord injury)

15. Under on-going care of a Physician (give name &

phone number below) for chronic or recurring problem

16. Do you wear glasses OR contact lenses? (circle)

17. Currently taking medication (list names & doses below)

18. Currently taking medication that needs refrigeration

19. Date of last TETANUS BOOSTER _______________

Please provide any detailed information for any items above marked above. Be specific.

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Family Doctor:___________________________________________________________________________________________

Clinic/Hospital Affiliation:_________________________________________________________________________________

City:___________________________________________________ Phone: (______)___________ -_________________

Medical Privacy Statement: It is the policy of University of Illinois Extension 4-H Youth Development Programs to keep any medical information it may have regarding Youth Development program participants confidential. However, there may be time in which such medical information will be needed and may need to be shared with others. Examples of sharing might include: providing information to medical personnel in the event of an emergency so that a youth may be treated; providing information to University staff or volunteers who are coordinating specific events in the case of a request for reasonable accommodation; and providing information to chaperones or host families who are re-sponsible for the health and safety of program participants at a specific event. Except in the case of emergency, prior to sharing any medical information, it may have with those external to the University, Extension, or 4-H, every effort will be made to get the permission of the program participant or parent or guardian. As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given. I further understand that in case of serious illness/injury, I will be notified. However, if it is impossible to contact me, I give my permission for emergency treatment, x-ray or surgery, as recommended by an attending physician. I also understand that any accident insurance in effect for the event, does not cover pre-existing conditions or self-inflicted injuries. I understand this insurance also may not cover all expenses and I will be responsible for payment of any expenses over and above the coverage provided.

SIGNED:________________________________________________________ DATE:________________________________ Parent or Guardian

Revised 2019

HEALTH INFORMATION STATEMENT

Place a “” in the box to highlight any information you feel staff and/or volunteers may need to maximize the safety and the well

being of the delegate/chaperon. At the end of the list, please give specific information on any items that you placed a “” in the

space. Please be specific. In case of emergency, this form may be the only immediate source of accurate important information.

COLLEGE OF AGRICULTURAL, CONSUMER & ENVIRONMENTAL SCIENCESUniversity of Illinois | U.S. Department of Agriculture | Local Extension Councils Cooperating University of Illinois Extension provides equal opportunities in programs and employment. If you need reasonable accommodations to participate, please contact the registration office.