Riverside/San Bernardino CountyHorse Camp
July 18-22, 2010
Los AngelesCountyFairgrounds
Camp is open to all 4-H Horses and Ponies project members in good standing in Riverside and San Bernardino counties. Horse leaders and parents are welcome as chaperones and there will be 1 chaperone required for every 5 campers. For camp attendance priority will be given to applications received first.
4-H Horse Camp provides scheduled activities throughout the day intended to improve riding skills and increase the camper’s knowledge about horses. Campers are expected to participate in all events. Please do not send a 4-H member to camp who is not interested in furthering his/her horse knowledge and wishes only to be on vacation.
The cost for camp is $165.00 per 4-H member with a $65.00 deposit required with application. The cost for chaperones is $50.00. Camp fees include all meals and snacks, beginning with dinner Sunday through Thursday lunch. Fees also include all activities, clinics, workshops, crafts, camp picture, and a campt-shirt. A box stall will be provided for your horse, but you must bring your own feed. If bedding is desired it must be straw. Shavings are not permitted.Stalls will need to be stripped before departure on Thursday.
We will have a limited number of spots available for horseless members and the cost for them is $85.00. Kids without horses will be able to observe and learn at all the clinics and will be able to attend all workshops, crafts, and horseless activities. They will also receive a camp picture and t-shirt. They will not be allowed to ride any horses during the time of camp, even if they have permission from the owner.
Clinics with horses may include: Showmanship, massage therapy, equitation, trail, jumping, gymkhana, dressage, driving, games, and reining. Clinics are subject to change. A complete list of clinics will be available soon. Non-riding events will include workshops and seminars by equine specialists. Craft classes will be offered each day.
There is some grass for tent camping. Please bring a tent, sleeping bag and toiletries. Sleeping in an empty stall or tack room will also be allowed. Showers and bathrooms will be available. Dry camping will be available for RVs but there will be NO hookups within the fairgrounds for electric or water. If hookup is desired there is a campground across White Ave.
Fairplex KOA/RV Park 2200 N. White Ave. Pomona, CA91768
Phone: (909) 593-8915
Reservations: (888) KOA-4230
4-H members may not stay in an R.V. without an adult. Each club must provide 1 chaperone for each 5 campers. Clubs with less than 5 may still need to provide an adult chaperone. Chaperones may not bring a horse.
All horses must have proof of current vaccinations, (i.e., vet certificate or proof of purchase of vaccines). Please send a copy with application.
Additional horses can be brought to camp by the 4-H members at an additional charge of $50.00 per horse.
The arrival time is Sunday, July 12, starting at 2:00 p.m. and throughout the rest of the day. Departure will be Thursday afternoon before 4:00 p.m. Please pick up your children and horses on time. There will be trailer parking available in the barn area. Empty stalls may be used for tack and feed storage if the horse trailer is not left, but please have 3-5 campers share a stall.
The camp location is at Fairplex, 1101 W. McKinley Avenue, Pomona, CA. 91768. Enter Gate 1 from McKinley Ave. There will be signs to direct you to the barn area.
Questions: Lynn Warren 951-845-7730
Riverside/San Bernardino CountyHorse Camp
July 18-22, 2010
Los AngelesCounty Fairgrounds
CAMPER APPLICATION
Please fill out the application form and return it by June25 with a completed medical treatment form, proof of current horse vaccinations, signed Safety Rule form, and a $65.00 deposit for horse campers and horseless campers. (Balance of $100.00 or $55.00 for horseless kid will be due July 3rd). If payment is not received in full by July 3rd, your spot may be given to someone else. Make checks payable to Riverside County 4-H Council and mail to:
Lynn Warren
9070 Whipsering Pines Rd.
Cherry Valley, CA 92223
Childs Lg.
Name______Age______T-shirt size: Adult Sm.
Med. Lg. XL
Address______Phone______
Club______Horses Name______Horeseless member yes no
Additional horses at the cost of $50.00 each______
Vegetarian meals? Yes No Any food allergies?______
Chaperone Name:______
E-mail address ______
What are your areas of interest?______
HORSEMANSHIP CAMPPARTICIPANT’S AGREEMENT
I have read and agree to abide by the horseman’s code of conduct and the rules established for my safety by the Riverside/San Bernardino County 4-H horse camp committee. This entry form certifies that I am nine years old, or older, and that I am enrolled in the 4-H horses and ponies project.
______
Member signature
My child has my permission to participate in the Riverside/San Bernardino County 4-H horse camp, July 18-22, 2010. I further authorize the adult in charge to do whatever he/she deems necessary, including obtaining necessary emergency treatment and/or placing him/her under a physician’s care in the event of illness or physical injury. I understand that while at this event, my child is expected to adhere to the 4-H Code of Conduct. I further acknowledge that a 4-H Release Agreement is on file at the 4-H Office. I have provided proof of vaccinations for our horse. As a parent/guardian of this child, I will make sure that he/she arrives and departs on time, and should it become necessary, I will pick up my child in a timely manner due to his/her misbehavior at the time it is requested without a refund of money paid. I have completed the required forms and I have listed all medications my child must take and I have instructed my child to turn this over to the adult in charge for dispensing during the course of this camp.
______(____)______(____)______
Parent/guardian signaturehome # work #
As the 4-H Horse project leader in the ______4-H club, I certify that this 4-H member is enrolled in 4-H and in the Horse project.
______
4-H Project Leader’s Signature
Riverside/San Bernardino CountyHorse Camp
July 18-22, 2010
Los AngelesCounty Fairgrounds
CHAPERONE APPLICATION
Fill out the application form and return it by June 25 with a $30.00 deposit (Balance of $20.00 due by July 3rd). Make checks payable to RiversideCounty 4-H council and mail to:
Lynn Warren
9070 Whipsering Pines Rd.
Cherry Valley, CA 92223
Sm. Med. Lg.
Name______T-shirt size: X-Lg. XXL
Address______Phone______
Club______
Vegetarian meals? Yes No Any food allergies?______
What is your area of interest? ______
Paddock supervisor/arena monitor______Night watch______
Clinician assistant______What discipline?______
Crafts______Meal Preparation ______Other______
e-mail address ______
HORSEMANSHIP CAMPPARTICIPANT’S AGREEMENT
I have read and agree to abide by the horseman’s code of conduct and the rules established for my safety by the Riverside/San Bernardino County 4-H horse camp committee. Release of liability waiver must be filled out. Only carded 4-H leaders will be covered by insurance and only
4-H leaders may ride horses.
Signature______
Adult chaperones are not allowed to bring horses to camp since we have limited stalls available and our 4-H horse camp is designed for the kids and their horses.
Statement of Safety Rules and Dress Code
4-H safety rules will be enforced during the horse camp and if a 4-H camper is warned twice and then has to be told a third time about a rule infraction that camper will be asked to leave camp and his/her parents will be called to pick up their child. Rules that will be STRONGLY enforced are that helmets and boots must be worn at all times while mounted. Closed toed shoes must be worn at all times while handling a horse. The 4-H dress code will also be enforced and therefore no spaghetti strap tank tops or bikini tops may be worn at camp. Tank tops must have at least a 1 inch strap. The midriff must be covered at all times.
I have read and I understand the 4-H rules for horse camp that have been stated above and I agree to abide by them.
______
Signature of 4-H memberDate
I have read and I understand the 4-H rules that my child need to abide by and I understand that if my child has to be asked a third time after being warned twice about a rule infraction, I will be called to pick up my child from camp.
______
Signature of parentDate
MEDICAL TREATMENT FORM – MINOR
University of California 4-H Youth Development Program
I hereby certify that my child is in good health and can travel to and participate in this 4-H function.
My Child / has my permission to attend thename of child
Riverside/San Bernardino CountyHorse Camp / located at or near / Los AngelesCounty Fairgrounds - Fairplex
city or town
in / Pomona, CA / between the dates of / July 19, 2009 / and / .July 23, 2009
state or county
While my child is 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 SAID MINOR:
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.
AUTHORIZATION AND CONSENT AND RELEASE
date / signature of parent/legal guardian / emergency phone DAYmailing address / 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 4-H Office informed.
NON-CONSENT
I do not desire to sign this authorization and understand that this will prohibit my child from receiving any medical attention in the event of illness or accident.
______
SIGNATUREDATE
PLEASE COMPLETE THE HEALTH HISTORY INFORMATION ON THE REVERSE SIDE.
University policy and the State of California Information Practices Act of 1977 requires the following information be provided when collecting personal information from you: 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 one or the other of the two signature lines above. Failure to provide the medical information and authorization may result in our inability to provide needed 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, One Shields Avenue, University of California, Davis, California 95616-8565. 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.
HEALTH HISTORY INFORMATION
(This information is confidential and will be used only in case of emergency.)
Name of 4-H Member: ______Social Security Number: ______/ Date of Birth: ______/______/______
(Optional) / MonthDayYear
Is your child subject to: / Yes / No / Does your child have or has ever had: / Yes / No
Colds / Heart Trouble
Sore Throat / Asthma
Fainting spells / Lung trouble
Bronchitis / Sinus trouble
Convulsions / Hernia (rupture)
Cramps / Appendicitis
Allergies / Has appendix been removed ?
Is the child 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?
Has the child been under psychiatric treatment within the past three years?
Date of Child’s last Tetanus Vaccination: / / /
M D Y
Please identify over-the-counter medications that we may administer. For example: Antacid, Aspirin.
Please identify child’s allergies, including allergies to food, medications, or drug reactions you know about:
Please list any disabilities or disorders that may affect your child’s participation at this 4-H function, such as eyesight,
hearing, speech, paralysis, diabetes, ulcer, etc.
Please list all medications that child is presently taking:
Name of Medication / Dosage / Times TakenRemarks and any special instructions. Please explain “Yes” answers on this page.