American Indian or Alaskan Native only ... African American & American Indian/ Alaska Native ... Parent/ Guardian: K
County
Michigan 4-H Companion Animal Camp Registration Packet Directions: Please determine the appropriate form for your registration type. Then submit your registration and payment directly to: Katie Ockert, 4-H Animal Science Educator 446 W. Circle Drive, Rm 240 East Lansing, MI 48824
Registrations are due by May 5, 2017 4-H Youth Members—Fill out and submit the following: Participant Registration Form 4-H Member Lodging Information 4-H Overnight Housing Parent/ Guardian Permission Form
4-H Leaders/Volunteers—Fill out and submit the following: 4-H Volunteer Registration Form 4-H Volunteer Lodging Information
Parent (Has not gone through MSU Extension’s Volunteer Selection Process)—Fill out and submit the following: Parent (Non-VSP Certified) Registration Form Parent (Non-VSP Certified) Lodging Form
County
Participant Registration Form To register for camp, complete and submit Lodging Form, and payment to Katie Ockert, 446 West Circle Drive, Rm 240 Justin Morrill Hall of Agriculture, East Lansing, MI. Please type or print in ink clearly. Make checks out to Michigan State University. Registrations must be postmarked by May 5, 2017. County Name Street
City
State
Zip
Phone
4-H club or group
Email
Number of years as a 4-H Member (as of 1/1/15)
Age
Birthday
**REQUIRED: My chaperone is: ___________________________________________________ Gender:
Male
Female
Racial – Ethnic Category: (Optional; for affirmative action purposes only)
White only African American/ Black only American Indian or Alaskan Native only Asian only Native Hawaiian/ Other Pacific Island only White & African American White & American Indian/ Alaskan Native African American & American Indian/ Alaska Native White & Asian Other (please specify) Residence Description: Farm or in the country Town or city with less than 10,000 people City with 10,000 – 50,000 people City with 50,000 – 100,000 people City with more than 100,000 people
County MSU is an affirmative-action, equal-opportunity employer. Michigan State University Extension programs and materials are open to all without regard to race, color, national origin, gender, gender identity, religion, age, height, weight, disability, political beliefs, sexual orientation, marital status, family status or veteran status.
4-H Member Lodging Information Name
County
Registration fee of $50 per person attending (includes cloverbuds and youth member) Complete the information below 1. I will be staying in (mark one): Camper/trailer Tent Lodge 2. Complete ONE Section: Each member must designate a chaperone. Chaperones must complete VSP and be same sex as members. (Female adults with female members, Male adults with male members) One chaperone is needed per campsite with ratio of one chaperone per 10 members aged 13 years and up and one chaperone per 6 members aged 12 and under in one campsite or building. *____ Camper/Trailer I will be bringing/staying in a camper/trailer. The parent staying in the camper trailer is ___________________________________________ (Name) *____ Tent I will be bringing/staying in a tent. The parent staying in the tent is ___________________________________________ (Name) *____ Lodge I will be staying in one of the lodges at Camp Tuchsmeheta The chaperone staying in the lodge from my county will be:
County
_____________________________________________________________ (Name and County) MSUE BOOKEEPING: Deposit checks in DS100057 sub 4410
4-H Overnight Housing Parent/ Guardian Permission Form Parent/ Guardian: Please complete the following information and return the top portion of this sheet to Katie Ockert, 446 West Circle Drive, Rm 240 Justin Morrill Hall of Agriculture, East Lansing, MI, postmarked by May 7, 2016. Keep the information at the bottom of the page for your records.
I understand that my child
will be attending (name of child)
on (name of event)
at
(date of event)
and that he or she may be sharing lodging with an (location of event)
unrelated adult (21 or older) who has been through the Michigan State University Extension Child Well-Being Volunteer Selection Process* and with at least one other youth. By signing this form I give my permission for my child to attend this event under these lodging conditions. I also understand the Michigan 4-H Code of Conduct** expectations for adults and youth attending this event.
Signature of Parent/Guardian
Date
Parent/ Guardian: Keep this information for your records: Name of Event: Michigan 4-H Companion Animals Camp Date of Event: June 3-5, 2016 Location of Event: Camp Tehsmeheta, Greenville, MI *For more information on the Michigan State University Volunteer Selection Process, contact your local 4-H staff member or go to http://web1.msue.msu.edu/msue/cyf/youth/cwbvsp.html ** Michigan 4-H Code of Conduct for 4-H Activities: Positive behavior is a key expectation for youth and adults participating in 4-H activities- behavior that reflects trustworthiness, respect, responsibility, fairness, caring and citizenship. Participants are expected to follow all workshop and event guidelines. Theft, vandalism, the use of illegal
County drugs and alcohol, inappropriate or threatening behavior that violates the rights of others, and other such offenses are strictly prohibited, and anyone involved with these offenses will immediately be sent home at his or her own expense. If it is determined by 4-H staff or persons in charge of the activity that the offense warrants it, the offender will be turned over to the proper authorities.
Chaperone Information Each county needs to send one chaperone for every 10 members (aged 13 and up) and one chaperone per 6 members (aged 12 and under). Chaperones are needed from each county for each of the lodging options that youth are staying at (i.e. if youth from your county are in both tents and lodges, chaperones will need to be in both places. If youth are only in one place, chaperones from your county only need to be at one place). Other than family units, chaperones can only chaperone members of the same sex in the campground and lodges. Female youth need female chaperones and male youth need male chaperones. They cannot be housed together. All
volunteer chaperones registered for camp must have completed the Volunteer Selection Process. Parents are highly encouraged to come, however cannot be allowed to stay in lodges with their children and other participants. Families are free to register for tent or camper lodging where they can stay as a family unit. Chaperones will be responsible for the supervision of county delegation during camp, especially during free times, meals, and overnight.
Chaperone Duties
Help your county members get checked in at the camp office and settled in their campsite or lodge. Work in conjunction with Camp Staff and other chaperons to supervise the behavior of all participants during camp. Work in conjunction with Camp Staff to answer questions or assist participants. Perform bed checks each night and report to Camp Staff when all participants are accounted for. Work in conjunction with Camp Staff to enforce quiet hours. Help session coordinators with sessions. Help resource people to ensure the camp is properly cleaned up before participants leave home on Sunday Stay at camp during the entire camp program.
County
4-H Volunteer Registration Form To register for camp, complete and submit your Lodging Form, and payment to Katie Ockert, 446 West Circle Drive, Rm 240 Justin Morrill Hall of Agriculture, East Lansing, MI. Please type or print in ink clearly. Make checks out to Michigan State University. Registrations must be postmarked by May 5, 2017.
County Name
Birthday
Street
City
State
Zip
Phone
4-H club or group
Email
I completed the Volunteer Selection Process in my county in (month/year) _________________ Gender:
Male
Female
Status: (check all that may apply) Field staff Chaperone (see head chaperone responsibilities on page 4 and must attend Saturday Meeting) Resource person Racial – Ethnic Category:
Residence Description:
(Optional; for affirmative action purposes only)
White only African American/ Black only American Indian or Alaskan Native only Asian only Native Hawaiian/ Other Pacific Island only White & African American White & American Indian/ Alaskan Native African American & American Indian/ Alaska Native White & Asian Other (please specify)
Farm or in the county Town or city with less than 10,000 people City with 10,000-50,000 people City with 50,000-100,000 people City with more than 100,000 people
County MSU is an affirmative-action, equal-opportunity employer. Michigan State University Extension programs and materials are open to all without regard to race, color, national origin, gender, gender identity, religion, age, height, weight, disability, political beliefs, sexual orientation, marital status, family status or veteran status.
4-H Volunteer Lodging Information Name
County
1. I will be staying in: (mark one) Camper/trailer Tent
Lodge
2. Complete ONE Section: *____ Camper/Trailer I will be bringing/staying in a camper/trailer. Complete Chaperon Coverage below Cost per camper/trailer ($50.00) I have enclosed $
*____ Tent I will be bringing/staying in a tent. Complete Chaperone Coverage below Cost per camper/trailer ($50.00) I have enclosed $
*____ Lodge I will be staying in one of the lodges at Camp Tuhsmeheta Cost per camper lodge housing ($50.00) I have enclosed $______
Complete the Chaperone Coverage below
3. Chaperone Coverage I will be providing chaperone coverage for the following members who will be housed in the same trailer/tent/lodge that I am staying in (Include name and county). Chaperones must complete VSP and be the same sex as the members. Female members need female chaperones and male members need male chaperones. They cannot be housed together. One chaperone is needed per campsite with ratio of one chaperone per 10 members (aged 13 and up) or one chaperone per 6 members (aged 12 and under). , , ,
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County ,
,
MSUE BOOKEEPING: Deposit checks in DS100057 sub 4410
Parent (Non-VSP Certified) Registration Form To register for camp, complete and submit your Lodging Form and payment to Katie Ockert, 446 West Circle Drive, Rm 240 Justin Morrill Hall of Agriculture, East Lansing, MI. Please type or print in ink clearly. Make checks out to Michigan State University. Registrations must be postmarked by May 5, 2017.
County Name
Birthday
Street
City
State
Zip
Phone
4-H club or group Gender:
Male
Email Female
Status: (check all that may apply) Field staff Chaperone (see head chaperone responsibilities on page 4 and must attend Saturday Meeting) Resource person Racial – Ethnic Category:
Residence Description:
(Optional; for affirmative action purposes only)
White only African American/ Black only American Indian or Alaskan Native only Asian only Native Hawaiian/ Other Pacific Island only White & African American White & American Indian/ Alaskan Native African American & American Indian/ Alaska Native White & Asian Other (please specify)
Farm or in the county Town or city with less than 10,000 people City with 10,000-50,000 people City with 50,000-100,000 people City with more than 100,000 people
MSU is an affirmative-action, equal-opportunity employer. Michigan State University Extension programs and materials are open to all without regard to race, color, national origin, gender, gender identity, religion, age, height, weight, disability, political beliefs, sexual orientation, marital status, family status or veteran status.
County
Parent (Non-VSP Certified) Lodging Form Name
County
4. I will be staying in: (mark one) Camper/trailer Tent
Lodge (if available)
5. Complete ONE Section: *____ Camper/Trailer I will be bringing/staying in a camper/trailer. Complete Chaperon Coverage below Cost per camper/trailer ($50.00) I have enclosed $
*____ Tent I will be bringing/staying in a tent. Complete Chaperone Coverage below Cost per camper/trailer ($50.00) I have enclosed $
*____ Lodge I will be staying in one of the lodges at Camp Tuhsmeheta; I acknowledge that lodging space for parents may be limited and I will be notified if lodging space is not available prior to camp.
Cost per camper lodge housing ($50.00) I have enclosed $______
6. Family Members—Family unit housing The following members will be housed in the same trailer/tent with their family unit. , ,
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,
,
,
County
MSUE BOOKEEPING: Deposit checks in DS100057 sub 4410
