Revved up for 4-H…2017

Name ______4-H Age______Male Female

Address______City ______Zip Code ______

Email address ______

County in which you are a 4-H member ______Birth Date: ______

Roommate Preference (Roommate must be in the same age range) ______

Parent/Guardian Information

Name ______Home Phone ______

Address ______Work Phone ______

Alternate Emergency Contact:

Name ______Day Phone ______

Relationship ______Night Phone ______

Ethnicity (Circle one)1)Hispanic 2)Not Hispanic

Race (Circle all that apply) 1)White 2)Black 3)Alaskan/Am. Indian 4)Asian 5)Hawaiian/Pac. Island

Residence (Circle one) 1)Farm 2) Rural/10,000 3)Town 10-50,000 4) Suburb 50,000+ 5)City 50,000+

This form must be accompanied by a complete and signed Youth Health Form and Swim Waiver

MU: An equal opportunity/ADA institution

If you need accommodations because of a disability or if you need special accommodations, please contact your Youth Specialist before turning in this form.

Health and Authorization forms for 4-H Camp

To print a form from 4HOnline:

Health Form

Login

  1. Select “Continue to Family”
  2. Under “Member Reports” select the 4-Her you need a form for from the drop down menu.
  3. Select the “Health Form” from the next drop down menu.
  4. A PDF will download to your computer. Print it and turn in to the appropriate location.

Authorization Form

Same procedure only select “Authorization Form” from the second drop down menu.

Before you bring your form to the Extension Center to register:

Please have parents/guardians sign your forms with a “real” signature just as you have in the past and have them notarized. This will ensure services can be offered in the case of an emergency.

MISSOURI 4-H Camp

Revved up for 4-H!

SWIM TEST PERMISSION FORM CAMP

Camper Name ______

Each summer every child takes a mandatory swim test before they are allowed to go in the deep

end of the pool. The children who prove themselves able to swim wear a bracelet and all others

are limited to the shallow end of the pool. Awareness of the campers’ swimming ability is a serious

issue at camp. If you feel your child/children does not have the experience or ability to swim in the

deep end of the pool, please let us know.

______Knowing my child’s/children’s swimming ability, I feel my child/children should

not swim in the deep end of the pool.

______My child/children has/have my permission to take the swim test to see if his/her

abilities meet the 4-H Camp standards to swim in the deep end of the pool.

Parents/guardians of children participating in swim and water activities as part of their 4-H Camp experience, please indicate any health restrictions your child may have that would limit or prohibit

them from participating in swimming or other water related activities:

I/ We certify that any physical limitations or health restrictions have been noted above and on my child’s health form.

Parent/Guardian Signature______Date______

Parent/Guardian Signature______Date______