Dubuque County Trailblazers Horse & Pony Camp June 20 – 26, 2010 Dubuque County Trailblazers 4-H Horse & Pony Camp June 20 -26, 2010 Application Form Mission The mission of the Dubuque County Trailblazers 4-H Horse and Pony Camp is to provide an educational opportunity for boys and girls to learn and improve their horsemanship and equitation skills through special sessions in advanced western riding, games, English riding, roping, and showmanship. Furthermore, our mission is to facilitate the makings of new friendships and bonds amongst our campers whom share a common passion for horses. Eligibility, Camp Registration Fee & Application Process The camp is open to boys and girls that have completed 4th grade and up and through 12th grade. Campers do not have to belong to 4-H. Camp registration fee is $250.00. This fee includes: the camper’s room and board for the week, camp t-shirt, box stall for the horse, and entry fee’s for the show that is held at the end of the camp week. Applications and a check for the FULL registration fee must be post marked by May 15, 2010 and mailed to: Dubuque County Trailblazers Horse & Pony Camp Attn: Katie Kotz 14957 Old Hwy Rd Dubuque, IA 52002 *Checks will not be cashed until after May 15, 2010 Application forms will be accepted until the camp is full, once the camp is full campers will be put onto a waiting list. Consideration will be given to those whose parents volunteer their time through out the camp week. You will be notified by email whether or not your camp application was accepted. If accepted, an email will be sent to you regarding final necessary camp information and equipment check list. Other Requirements Camper: Campers must carry their own insurance on themselves, their horses, and their tack. The camper is responsible for providing their own hay, other feed if needed, and bedding for their horse’s stall. All campers must have an ASTM or SEI approved riding helmet. This helmet must be worn at all times while mounted on the horse. Appropriate riding boots are also required by all campers while mounted on their horse. It must be emphasized that campers are expected to be able to feed their own animals, keep the stall clean, care for and control their animal. Campers should also be capable of bridling and saddling. Horse: Bring only experienced, well broke horse and ponies to camp. Horse and ponies less then four years of age, unbroken or very green horses, stallions, or mares with foals at side will not be allowed. Please make sure that your horse or pony is in good condition for camp. We recommend your horse be ridden at least one hour per day for three weeks or more prior to camp. We also recommend that a professional farrier trim or shoe your horse/pony 3 to 5 weeks prior to camp. All horse are required to have HEALTH papers dated within 30 days of the camp by a veterinarian. It is strongly recommended that your horse/pony be up to date on influenza, strangles, west nile and rhino vaccinations. All out of state horses will be required to have a negative coggins test. Scholarship Information Kelly Meier Memorial Scholarship - Must by enrolled in Grant County 4-H & be in 4th grade or above. Contact Kathy McPhail, Grant County Extension Office, PO Box 31, Lancaster, WI. 58313. (608) 723-2125 Iowa 4-H Foundation – The Iowa 4-H Foundation sets aside funds to help youth attend ISU Extension 4-H Camps. If you are in 4-H, contact your local extension office and ask for a financial aid from (VI-309-FS) Forms need to be returned to the extension office by May 1, 2010. For further information contact: Karen Schilling Katie Kotz Tammy Moore email@example.com firstname.lastname@example.org email@example.com 563-590-6419 (cell) 563-599-6528 (cell) 563-599-7777 (cell) Camper Application Form Name: __________________________________________________________________ Sex: Female Male Age (As of June 20, 2010): ___________ 09’/10’ Grade Completed: ___________ Address: ________________________________________________________________________________________ City: ________________________________________________ State: ____________ Zip: ___________________ Parent(s) Names: _________________________________________________________________________________ Phone Number: ___________________________________ Cell Number: _________________________________ EMAIL ADDRESS (required): _____________________________________________________________________ If you do not have an email address please indicate here by checking this box. Camper T-Shirt Size (one shirt included in the camp cost, these are adult sizes): S M L XL XXL Additional shirts maybe purchased at $12.50 each. Size of Shirt ________ Quantity ________ X $12.50 = $____________________ Size of Shirt ________ Quantity ________ X $12.50 = $____________________ Camper Placement Questionnaire Have you been to camp before? ___ Yes ___No How many years have you been riding? _______________ How would you rate yourself? Check ONLY one. 1 lowest, 3 highest: ___ Beginner 1 ___ Beginner 2 ___ Beginner 3 ___ Intermed 1 ___ Intermed 2 ___ Intermed 3 ___ Advance 1 ___ Advance 2 ___ Advance 3 Types of riding that you participate in regularly. Check all that apply ___Trail/Pleasure ___Western Pleasure/Show ___Games/Rodeo ___English ___Jumping ______________Other Please indicate how well you can do these listed skills: 1=Not at All, 2=Somewhat, 3=Well, 4=Exceptional Walk____ Trot____ Collected Canter/Lope____ Stop____ Back____ Post____ Correct Leads____ Direct Rein____ Neck Rein____ Side Pass____ Turn on Hind Quarters____ Turn on Forehand____ Warning: Under Iowa law, a domesticated animal professional is not liable for damages suffered by, an injury to, or the death of a participant resulting from the inherent risks of domesticated animal activities, pursuant to Iowa Code Chapter 673. You are assuming inherent risks of participating in this domesticated animal activity. A number of inherent risks are associated with a domesticated animal activity. A domesticated animal may behave in a manner that results in damage to property or an injury or death to a person. Risks associated with the activity may include injuries caused by bucking, biting, stumbling, rearing, trampling, scratching, falling, or butting. The domesticated animal may react unpredictably to conditions, including, but not limited to, a sudden movement, loud noise, and unfamiliar environment, or the introduction of unfamiliar persons, animals, or objects.The domesticated animal may also react in a dangerous manner when a condition or treatment is considered hazardous to the welfare of the animal; a collision occurs with an object or animal; or a participant fails to exercise reasonable care, take adequate precautions, or use adequate control when engaging in a domesticated animal activity, including failing to maintain reasonable control of the animal or failing to act in a manner consistent with the person’s abilities. ANY CAMPER MAY BE SENT HOME FOR ANY OF THE FOLLOWING REASONS: 1. Leaving the grounds without camp staff permission. 2. Leaving the dorm units after curfew without permission. 3. Possession and/or use of alcoholic beverages or other drugs. 4. Possession and/or use of Tobacco (smoking or chewing) 5. Switching stalls without permission. 6. Causing intentional damage to public or private property - camper will be charged for repairs. 7. Inappropriate conduct at camp. Any camper sent home for any of the above reasons will receive no refund, whole or part, and will not be considered for camp next year. We, parent(s) and camper, have read and agree to abide by the rules and conditions as stated above. The above named prospective camper has permission to take part in the Dubuque County Trailblazers 4-H Horse and Pony Camp. We understand that applicant acceptance makes the registration fee non-refundable except in the instance of camp cancellation, in which case your check will be returned. Signature (parent/guardian) __________________________________ Signature (camper) _________________________________________ Volunteer Sign-up Dear Parents: In order for us to operate as a 24-hour-a-day camp for one week at such a low fee, our camp relies HEAVILY on volunteer help. Each camper must have at least one parent volunteer. Please fill in form below, we will put you down to work the time you have indicated, a schedule will be mailed to you prior to camp. THANK YOU. Please print clearly. Volunteers Name ________________________________ Email ______________________________________ Phone _____-_________-____________ Add._____________________________________________ City_________________________ State ___________ Zip __________ Please fill in the spot of your preference, or you will be assigned to a needed position. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Girls Dorm Boys Dorm Kitchen Nurse Barn - Day/Night Daytime Chap. Food Stand -------- -------- -------- -------- -------- -------- Arena Help -------- -------- -------- -------- -------- -------- Nightly Demo. -------- -------- Please indicate arrival and departure times in table above. If you cannot volunteer during the week, please take a turn either on Sunday evening when you check in your child or in the food stand and/or arena on Saturday. Please mark this clearly – write notes – anything to help me determine what works best for you. Those not volunteering will be assigned to help clean the dorms on Saturday morning. Volunteer Duties: Overnight Chaperones: Boys & Girls 8:00 PM - 8:00 AM. Bring flashlight, sleeping bag, cot, etc. Preferable if you can help with breakfast 7:30-8:30 am Daytime Chaperones: Help organize and supervise free time activities. Help - we need activities for all ages, 10-18. Volleyball, T-ball, & Crafts, etc. Kitchen Help: Would like help with all three meals 7:00am - 6:30pm. If this is not possible, please indicate times you can be available. Barn Help: Patrol barns, check stalls, help in wash rack, etc. Nurses: Daytime help 8:30 am - 8:00pm. Mark times if you can do a split shift. Lunch Stand Help: 2 hour shifts - Sat 9 am - ? During Show Gatemen & Arena Help: 2 hour shifts - Sat 9 am - ? During Show Friday Afternoon Prep food stand at arena for show. Saturday Morning Cleaning Dorms & Kitchen Nightly Demonstration: Looking for Nightly Educational/Entertaining Demonstrations 1-2 hrs We greatly appreciate volunteers who can stay all week; this helps the camp run smoothly. The success of the camp is directly attributed to the many volunteers we rely on. Thank you for your time and generosity! All volunteers must check in at the kitchen prior to duty and receive a nametag to wear while on camp grounds.