1999 FOR CAMPERS ONLY 1999 by OznN8nG9

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									TO:               Adult Volunteers Interested in being Chaperones at
                         Marin County 4-H Camp 2011

FROM:             Eileen Castelli, Marin County 4-H Camp Clerk

RE:               Chaperone Application and Job Descriptions
Our Marin County 4-H Camp at Las Posadas, July 10 to July 16, is strictly a volunteer effort. We invite all interested adults to apply for
a chaperone position. Please read the position descriptions and submit your application no later than March 1, 2011. Adult
chaperones will be accepted following a selection process. If you would like to join us at camp for only ½ week, we will try to find
someone for the other half. Adults who can attend the full week will be extremely helpful. In the event there are more chaperones than
needed, we will develop a waiting list.

This year, our camping program will run from Sunday, July 10 through Saturday, July 16. The Adult Chaperone fee is $85.00. You
may want to ask your club or group to help with your fees. Please read the following positions carefully and if you have any questions
call Eileen Castelli at (707) 996-0354. We hope to hear from you soon.

                                                 ADULT CHAPERONE POSITIONS
There must be a ratio of one Adult Chaperone for each 10 youth in camp. These adults chaperone the campers in the sleeping areas
during rest periods and bedtime. All adults take an active role in camp during assigned activities. The youth staff runs the camp and the
chaperones are there to enhance the program only. “CAMP IS FOR THE CAMPERS” All adults must be fingerprinted
through the 4-H program. If you have not been fingerprinted previously through the 4-H program, please
request a fingerprint packet from the 4-H Office. (707)-499-4207 Fingerprints must be completed by June 1st.
ADULT CAMP SUPERVISOR: Coordinates camping program before and during week of camp. Works with Staff Advisor to train
Youth Staff. Works with session advisors to implement programs. Reports to Camp Executive Committee and Camp Clerk. Must have
three years Marin County 4-H Camp experience.

STAFF ADVISOR: Works directly with Youth Staff to plan, implement and coordinate camp. Coordinates staff training and advises
staff at camp. Works closely with Adult Camp Supervisor. Must have two years Marin County 4-H Camp Experience.

SPECIAL EVENTS ADVISOR: Works with Special Events Directors to plan and implement activities and parties during week of camp.

CRAFT ADVISOR (S): Plans, coordinates, and implements camp crafts program during free time.

RECREATION ADVISOR: Works with staff to plan and implement a Recreation Program for camp.

CAMPFIRE ADVISOR: Works with Campfire Directors to plan campfire programs.

SPORTS ADVISOR: Works with staff to plan and implement all sports activities and tournaments during camp.

NATURE ADVISOR: Works with staff to plan and implement camp Outdoor Education, Nature Sessions and free time hikes.

CAMP CHAPERONE: Will be assigned to a tribe to be a shadow during all events assisting tribe leaders as needed. Help with crafts,
hikes, K.P., swimming and be a good, positive role model for the youth staff. Volunteers or will be assigned other jobs as needed.

Please note: The Staff and Adult overnight training weekend will be April 30 – May 1, 2011 at Camp. Please make plans to attend
this important weekend. More information on this to follow.
All adult leaders and chaperones must be fingerprinted to participate in the 4-H program.
Eileen Castelli, Camp Clerk
707/996-0354
Marin4Hcamp@aol.com


                                               Keep this page for your reference
                                         2011                           FOR ADULTS ONLY                                    2011
                                                                         July 10 – 16, 2011
                      MARIN COUNTY 4-H CAMP ADULT REGISTRATION AND MEDICAL TREATMENT FORM

Name_________________________________________________     Currently Enrolled
                                                          in 4-H Club (name)
Address_________________________________________________________________ Phone

Birth date: ________________________Age: ___________ Sex: ________ Year in 4-H_________________

Years at MARIN Co. 4-H Camp___________________

Ethnicity: (X) American Indian/Alaskan Native______ Hispanic______ Black______ White______ Asian/Pacific Islander______

Vegetarian?                        Food Allergy?                     What food(s)?

T-shirt Size (adult sizes only) Small         Medium                           Large                  X-large               XX-large
(A T-shirt and camp picture is included in the camp fee)

REGISTRATION: COMPLETE ONE FORM PER ADULT. After completing both sides of this form mail it with your signed
Code of Conduct and Camp Fees ($85.00) (made payable to MARIN COUNTY 4-H CAMP) to MARIN County 4-H Camp,
C/O Eileen Castelli, 840 Bowen Ct., Sonoma, CA 95476. (Fees due no later than June 15th.)

I hereby certify that I am in good health and can travel to and participate in this 4-H function.
   While I am attending or traveling to or from this 4-H function, I HEREBY AUTHORIZE THE ADULT 4-H
LEADER OR STAFF MEMBER, or in his/her absence or disability, any adult accompanying or assisting him/her, TO
CONSENT TO THE FOLLOWING MEDICAL TREATMENT FOR MYSELF: Any X-ray examination, anesthetic, medical or surgical
diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician
and/or surgeon licensed under the provisions of the Medical Practices Act, California Business and Professions Code section 2000 et seq; or any X-ray
examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered by a dentist licensed under the provisions of the
Dental Practices Act, California Business and Professions Code section 1600 et seq.
   This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective until
my child completes his/her activities in this program unless sooner revoked in writing. I understand that as a parent/legal guardian, I will be responsible
for the cost of any service or treatment provided not covered by the 4-H Youth Accident Insurance Program sponsored by the University of California
Cooperative Extension
   I understand that participation in 4-H activities includes activities around animals and in the outdoors, and all the risks that accompany such
activities. I therefore waive any claims and agree to release and hold harmless The Regents of the University of California 4-H Program, its officers,
agents, and employees from any liability whatsoever.

 __________________________________________________________________________________________

                                      AUTHORIZATION AND CONSENT AND RELEASE
____________             ________________________________________________________                                                 _______________________
Date                     signature of ADULT                                                                                        emergency phone DAY


Mailing address

City                                                           ZIP code                                               emergency phone NIGHT

Should there be any changes in the status of parent/legal guardian, it will be my responsibility to keep the county officers informed.


University policy and the state of California Information Practices Act of 1977 requires the following information be provided when collecting personal information from
you about your child The information entered on this form is collected under authority of the Smith-Lever Act. Submission of the medical data is voluntary. However, a
signature is required on the signature line above. Failure to provide the medical information and authorization may result in our inability to provide ''ceded medical
treatment. You have the right to review university records containing personal information about you/your child, with certain exceptions as set forth in policy and statute.
Copies of university policies pertaining to the collection, use, or release of personal data are available for your examination at the Division of Agriculture and Natural
Resources, 4-H, DANR, North Central Region, university of California, Davis, California, 95616 Only your own/your child's records are open to your review. Any known
or foreseeable intergovernmental transfer which may be made of the information is as follows None.                                                                    2
                                                     HEALTH HISTORY INFORMATION

Name of Adult_________________________________ SS#___________________________________

E-Mail address (please print)_____________________________________________________________
I am subject to:                                        Yes        No       Do you now have or have you ever had:                                    Yes   No

Colds...................................                                    Heart trouble.................................................
Sore Throat.........................                                        Asthma.........................................................
Fainting spells.....................                                        Lung trouble..................................................
Bronchitis............................                                      Sinus trouble.................................................
Seizures........................                                            Hernia (rupture)............................................
Cramps................................                                      Appendicitis..................................................
Allergies..............................                                     Has appendix been removed?......................

Are you currently under any type of medical treatment?                      ......................................................................

Is there any history of behavior disorders or emotional disturbances, such as difficulties in
relationships with authority figures or peers, or abnormally severe moodiness?..............................

Have you been under psychiatric treatment within the past three years?.......................................

List when you were last vaccinated for:
Diphtheria                                                                  Tetanus
Polio                                                                       MMR (Measles/Mumps/Rubella)

Please identify any allergies, including allergies to foods, medications, or drug reactions you know about:




Please list any physical disabilities or disorders that may limit your activities at this 4-H function, such as eyesight,
hearing, speech, paralysis, diabetes, ulcer, etc.:




Please list all medications you are presently taking:




Remarks and any special instructions. Please explain "Yes" answers on this page.




In accordance with applicable State and Federal laws and University policy. the University of California does not unlawfully discriminate in any of its
policies, procedures, or practices on the basis of race, religion, color, national origin, sex, marital status, sexual orientation, age. veteran status, medical
condition or disability. Inquiries regarding this policy may be addressed to the Affirmative Action Director, University of California Division of Agriculture
and Natural Resources. 300Lakeside Drive. 6th Floor, Oakland, CA 94612-3560


Issued in furtherance of Cooperative Extension work. Acts of May 8 and June 30, 1914. In cooperation with the U.S. Department of Agriculture. W.R.
Gomes, Director of Cooperative Extension University of California.


                                                                                                                                                                   3
                                       CODE OF CONDUCT
                               MARIN COUNTY 4-H CAMP RULES
                         LAS POSADAS STATE FOREST, ANGWIN, CALIFORNIA

1.   Be polite and considerate of others and do not push, throw rocks, food, or any other items.
2.   Sexual harassment is never permitted. Never use racial, sexual, or religious slurs.
3.   Respect authority.
4.   Respect the property of others and do not disturb it.
5.   Respect the wildlife and do not harm any animals.
6.   Practice safety: firecrackers, fireworks, slingshots, guns and knives are not allowed.
7.   Preserve our camp atmosphere – do not bring alarm clocks, hair dryers, curling irons, food,
     radios, MP3 player, discman, electronic games, pagers, and cell phones.
8. Respect the camp schedule and always stay with the tribe or program to which you are assigned.
9. Closed toe shoes are required at all times. “Flip flops” may be worn in the shower only.
10. You may leave camp only with the permission of the adult Camp Supervisor and with 2 adults
     chaperone, parent or advisor to accompany you.
11. Hikers require permission from the Nature/Hike Leader; must sign out/in, and must be
     accompanied by two adults. Long pants, socks, and sturdy shoes will be worn on all hikes.
12. Alcohol and illegal drugs may not be brought to camp or be used at camp.
13. Smoking by campers is not permitted and chewing tobacco may not be used anywhere at camp.
14. Practice safety in camp: walk (do not run), and stay on trails.
15. Parking lot is off limits. No loitering or using vehicles while at camp.
16. Campers will remain in their assigned sleeping areas at night.
17. No boys in girl’s sleeping area, and no girls in boy’s sleeping area at any time.
18. Per 4-H policy, section 819, the person and property of all 4-H Youth Development Program
    (YDP) participants (both youth and adult) are subject to search during the course of 4-H
    YDP events if deemed necessary by 4-H YDP appointed volunteers and/or staff.

The penalty for infraction of these rules may result in any or all of the following:

     a.   Confiscation of inappropriate materials
     b.   Punishment as determined necessary by the Camp Review Team
     c.   Your parents will be called to come and take you home
     d.   You will be disaffiliated from the Marin County 4-H Youth Program

I HAVE READ THE CAMP RULES AND AGREE TO ABIDE BY THEM WHILE
ATTENDING THE MARIN COUNTY 4-H CAMP.

_________________________________________                          _________________________
Signature of Adult Participant                                        Date

Please return CODE OF CONDUCT with your REGISTRATION/MEDICAL FORMS, WAIVER OF
LIABILITY and FEES to EILEEN CASTELLI, 840 Bowen Ct. Sonoma, CA 95476.
   Questions: 707/996-0354 or Marin4HCamp@aol.com


                                                                                               4
            CHAPERONE APPLICATION FOR MARIN COUNTY 4-H CAMP 2011

Name______________________________________________________________________

Address __________________________________________Telephone (___) ____________

City_____________________________________________e-mail_____________________

Zip ________________________                    Fax_            ____________________

Currently enrolled in 4-H Club/Group_____________________________________________

Years with 4-H__________________ Years Marin Co. Camp experience______________
Please list any of your family that might be attending Camp with you so we can reserve a space for
them.

Name ___________________________________________ Age_____________

Name ___________________________________________ Age ____________

List your major interests and activities
______________________________________________________________________                   ____



What positions are you applying for?

       1st Choice_____________________________________________

       2nd Choice____________________________________________

       3rd Choice_____________________________________________

In what capacity are you working with youth at this time? ___________________________


Complete the above application and sign the Code of Conduct/Camp Rules on the back of this sheet.
Return along with the Adult Medical Release/Registration Form no later than March 1st to:
                       Eileen Castelli
                       840 Bowen Ct.
                       Sonoma, Ca. 95476
                       707/996-0354

The above application is true and correct.

Signed: ____________________________________________Date:____________________
                                                                          5
                                                               Participant’s Name_____________________________
                                                                                             Please print



                                          UNIVERSITY OF CALIFORNIA
                                 DIVISION OF AGRICULTURE & NATURAL RESOURCES
                                           4-H Youth Development Program
                                        Marin County Cooperative Extension

                          Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In Consideration of being permitted to participate in any way in California 4-H Activities and Projects, I,
for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to
sue The Regents of the University of California, its officers, employees, and agents from liability from any and all
claims including the negligence of The Regents of the University of California, its officers, employees and
agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not
limited to, participation in California 4-H Activities and Projects.

_______________________________________                     ______________________________________
Signature of Parent/Guardian of Minor         Date          Signature of Adult Participant                  Date

Assumption of Risks: Participation in California 4-H Activities and Projects carries with it certain inherent risks
that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to
another, but risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye
injury or loss of sight, joint or back injuries, heart attacks, and concussions 3) catastrophic injuries including
paralysis and death.

        I have read the previous paragraphs and I know, understand, and appreciate these and other risks
that are inherent in California 4-H Activities and Projects. I hereby assert that my participation is voluntary
and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the University of
California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities,
including attorney’s fees brought as a result of my involvement in California 4-H Activities and Projects and to
reimburse them for any such expenses incurred.

Severability:      The undersigned further expressly agrees that the foregoing waiver and assumption of risks
agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any
portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and
effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity
agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right
to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a
complete and unconditional release of all liability to the greatest extent allowed by law.


________________________________________                    ______________________________________
Signature of Parent/Guardian of Minor          Date         Signature of Adult Participant                   Date
Participant’s Age (if minor) __________

                                                                                                                    6
                       University of California Division of Agriculture and Natural Resources
                                          4-H Youth Development Program
                                    Volunteer Confidential Self-Disclosure Form
_______________________________________                                         _________________________________________________
Name of 4-H Club/Unit                                                                  First Name                   Last Name

_______________________________________________________________________________________________
Mailing Address                            City                 State          Zip

The purpose for requesting the information on this form is to provide a safe environment for young people involved with 4-H activities.
Furnishing all information requested on this form is mandatory. Failure to provide this information will delay or prevent
appointment as a 4-H Volunteer. Local programs may also require additional information before appointing 4-H volunteers. University of
California policy authorizes maintenance of this information. Individuals have the right to review their own records in accordance with the
Division of Agriculture and Natural Resources Administrative Handbook, Section 402. Information on these policies may be obtained from
the Controller and Business Services Director, Agriculture and Natural Resources, University of California, 1111 Franklin Street, 6th Floor,
Oakland, CA 94607-5200, or via the Internet at: http://danr.ucop.edu. The official responsible for maintaining the information contained on
this form is the Cooperative Extension County Director.

1.     Have you been convicted of a felony in the last ten years?                                                                                       Yes                         No

2.     Has anyone living with you been convicted of a felony in the last ten years?                                                                     Yes                         No

3.     Have you ever been convicted of child abuse, neglect, or any sex offense?                                                                        Yes                         No

4.     Has anyone living with you ever been convicted of child abuse, neglect, or any sex offense?                                                      Yes                         No

5.     Has your driver’s license been suspended or revoked in the last ten years?                                                                       Yes                         No

6.     Are there any other facts or circumstances involving your background or background of                                                            Yes                         No
       others in your household that would call into question your being entrusted with the
       supervision, guidance, and care of young people?

7.     Do you have a valid driver’s license? State________________________________                                                                      Yes                         No

8.     University of California (UC) requires volunteers to maintain minimum automobile liability
       coverage of $50,000 per accident claim/$100,000 in aggregate/ $50,000 for property damage.
       Do you have this level of coverage?                                                                                                              Yes                         No

       If no, what is your coverage? _________per accident, _________in aggregate, _________property damage?

9. I understand that UC provides secondary liability coverage in the event of an accident during
   4-H business and if my coverage is below the UC minimums, I am liable for the difference
   between my policy limits and UC’s secondary coverage.                                                                                             ______initial

10     If you answered “Yes” to questions 1-6, or “No” to 7 or 8, please explain:

By signing below, I certify that the information above and on my application is true and correct. In addition, I have read,
understand and agree to the terms of the 4-H Code of Conduct/Responsibilities and Rights and Photograph and Information
Release. I am aware that I must re-apply for a 4-H Volunteer appointment annually, and provide an updated Adult Medical
Release Form, Waiver of Liability, and Volunteer Confidential Self-Disclosure Form. I also understand that this application must
be approved and my fingerprints cleared through the Department of Justice before my service as a volunteer begins. Volunteer
appointments are for a period of one year.
_______________________________________________                                                            _______________
Applicant Signature                                                                                        Date

     Instruction to the Applicant: Place this application in a “confidential” envelope and sign along the seal. The sealed envelope must be forwarded to the
     County Cooperative Extension/4-H Office.

                     The University of California prohibits discrimination or harassment of any person on the basis of race, color, national origin, religion, sex, gender identity,
                     pregnancy (including childbirth, and medical conditions related to pregnancy or childbirth), physical or mental disability, medical condition (cancer-related or
                     genetic characteristics), ancestry, marital status, age, sexual orientation, citizenship, or service in the uniformed services (as defined by the Uniformed Services
                     Employment and Reemployment Rights Act of 1994: service in the uniformed services includes membership, application for membership, performance of
                     service, application for service, or obligation for service in the uniformed services) in any of its programs or activities. University policy also prohibits reprisal
                     or retaliation against any person in any of its programs or activities for making a complaint of discrimination or sexual harassment or for using or participating
                     in the investigation or resolution process of any such complaint. University policy is intended to be consistent with the provisions of applicable State and
                     Federal laws. Inquiries regarding the University’s nondiscrimination policies may be directed to the Affirmative Action/Equal Opportunity Director, University

                                                                                                                                                                                         7

								
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