2015 National 4-H Shooting Sports Teen Leadership Institute August 4 - 8, 2015 California State University, Fresno Application Packet Deadline – May 15, 2015 to your 4-H Shooting Sports State Coordinator Please prepare a complete application packet and mail or email your application to your state 4-H Shooting Sports Coordinator. State Coordinators will select two applications, identify one as the primary candidate and one as the secondary candidate and forward the two applications to Lisa Muzzey, National 4-H Shooting Sports Committee. The secondary candidate will be accepted depending on space availability. Applicants must be at least 15 years of age by January 1, 2015 to apply. It is recommended that the candidates also have at least one year left in 4-H. All lodging (including linens), meals, transportation during the event and materials will be provided by generous donations from the National 4-H Shooting Sports Steering Committee General Fund. The cost and arrangement of transportation to the event will be the responsibility of the participant. Participants should plan to arrive between 2:00 - 8:00 p.m. on Tuesday August 4, 2015. The event will conclude on Friday evening August 7, 2015. Youth will depart campus between 7:00 a.m. – 10:00 a.m. on Saturday, August 8, 2015. Transportation to and from the Fresno Yosemite International Airport is provided. A completed packet includes the following: 1. 2. 3. 4. 5. 6. 7. Letter of reference from your state 4-H SS Coordinator (done after state selection) Resume for Teen Applicant - include school, 4-H, community memberships, activities and awards California 4-H Member Code of Conduct Form California 4-H Medical Treatment Authorization Form California 4-H Waiver of Liability, Assumption of Risk, and Indemnity Agreement Form National 4-H Shooting Sports Youth Leadership Institute Application Form National 4-H Shooting Sports Youth Leadership Institute Certification Form (complete with all signatures) 8. One 5 x 7 – Portrait Color Photograph and Digital Copy (jpeg or tif) Send completed application packet to: Gerry Snapp 1110 S. College Ave Columbia, MO 65211 (573) 882-5547 Due to State Coordinator by May 15 Due to Lisa Muzzey – National 4HSS – June 1 Selection confirmation by June 15 University of California, Division of Agriculture & Natural Resources 4-H Youth Development Program Member Code of Conduct The 4-H Policy Handbook tells me my rights as a 4-H member, and the rules I have to follow. 4-H calls the most important rules for members the “Code of Conduct”. When members follow the Code of Conduct, it helps keep 4H safe and fun for everyone. I will follow the 4-H Code of Conduct (rules) and I will: 1. Be nice, kind, helpful, and respectful to other 4-H members; and to adult volunteers, youth leaders, 4-H staff, and other adults in charge. 2. Be honest, honor my commitments, and accept responsibility for my choices. 3. Use language that is respectful and kind. Not use curse words. 4. Wear appropriate clothes that are allowed by 4-H rules. 5. Not have or use alcohol, tobacco (like cigarettes, e-cigarettes, or chew) or other drugs (unless my doctor gives them to me). 6. Not bother or attack others, not carry or use a weapon; and not do anything else illegal or unsafe. 7. Know that adults can search my things (like my backpack) if they think I might have broken the 4-H rules. 8. Not touch anyone in a way that is too affectionate, and not engage in sexual behavior. 9. Follow the 4-H Guidelines for Social Media - http://www.ucanr.edu/files/133821.docx. 10. Not do things outside of 4-H that are harmful to anyone in 4-H or the 4-H program. While attending 4-H overnight events I will: 1. 2. 3. Be in my room when I’m supposed to be there. Not leave the grounds unless an adult in charge gives me permission, and only if there are two adults with me. Not be in the girls’ sleeping area if I’m a boy, not be in the boys’ sleeping area if I’m a girl, and not invite any kids who aren’t 4-H members into the sleeping areas. Be responsible for any damage caused by my actions. Follow all the rules for that event. 4. 5. Consequences Anyone who sees someone break the Member Code of Conduct should tell the adult in charge right away. That adult will tell that member’s parent or guardian. Consequences for breaking the 4-H rules may include: 1. Sending the member home. 2. Having the member meet with 4-H adults, talk about how the member can learn from what they’ve done, and decide what the member should do to make up for any harm done. 3. Charging the member (or their parents/guardians) for the cost of repairs to property that the member damaged. 4. Giving the member a warning, barring them from future events, suspending their membership, or terminating their membership. 5. Taking the member to the nearest law enforcement agency or other proper authority. Photograph and Information Release I give to The Regents of the University of California, National 4-H Council, National 4-H Headquarters (USDA), Cooperative Extension and units, its nominees, agents, and assigns, unlimited permission to copyright and use, publish, and republish for purposes of advertising, public relations, trade, or any other lawful use, information about me and reproduction of my likeness (photographic or otherwise) and my voice, whether or not related to any affiliation with 4-H, with or without my name. I hereby waive any right that I (and minor) may have to inspect or approve the copy and/or finished product or products that may be used in connection therewith or the use to which it may be applied. County: Signature of Member: Date: Signature of Parent/Guardian: Date: Form Revised 7/1/2014 Youth Treatment Authorization Form This Treatment Authorization Form is authorized for all 4-H Youth Development meetings and activities during the dates specified below. (Note: This information must be updated annually) First Name Last Name Club/Unit Name From: August 1, 2015 to August 10, 2015 County and State While my child is attending or traveling to or from this 4-H function, I HEREBY AUTHORIZE THE 4-H ADULT VOLUNTEER OR 4-H 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/guardian, I will be responsible for the cost of any service or treatment provided not covered by the 4-H Accident/Sickness Insurance Program sponsored by UC Cooperative Extension. EMERGENCY CONTACT INFORMATION Name ( Relationship to Youth Identified Above ) Emergency Day Phone (with area code) Mailing Address ( ) Emergency Night Phone (with area code) City State Zip AUTHORIZATION AND CONSENT AND RELEASE I hereby certify that my child is in good health and can travel to and participate in all functions of the 4-H Youth Development Program as described above. I understand is it my responsibility to keep the information on this form updated (including Health History) by contacting the County 4-H Office. Signature of Parent/Guardian Date NON-CONSENT I do not desire to sign this authorization and understand that this will prohibit my child from receiving any non-life threatening medical attention in the event of illness or accident. Signature of Parent/Guardian Date University policy and the State of California Information Practices Act of 1977 require 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 necessary medical treatment. You have the right to review University records containing personal information about you, 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 from the local UCCE County Director, 4-H Youth Development Advisor, 4-H Program Representative or the Associate Director of 4-H Program & Policy at University of California, Division of Agriculture and Natural Resources, California State 4-H Office, 2801 Second Street, Davis, CA 95618-7774, (530) 750-1334, [email protected] Only your own records are open to your review. Health History Information / First Name Birth Last Name Subject to: Colds Sore Throat Fainting Spells Bronchitis Convulsions Cramps Allergies Wear corrective lenses? Is hearing good? / County YES No Date of Now Have or Have Had Heart Trouble Asthma Lung Trouble Sinus Trouble Hernia (rupture) Appendicitis Has appendix been removed? Do you walk in your sleep? Yes Date of last Tetanus Vaccination: Please check over-the-counter medications that may be administered: Tylenol Ibuprofen Hydrocortisone Cough Syrup Other: Decongestant Dramamine Antacid Polysporin Please identify allergies including allergies to food, medications, and drug reactions: Please list any disability accommodations you will need in order to participate in this program or activity. Please list all current medications: Name of Medication Dosage Times Taken Please include any additional remarks and special instructions to better assist emergency service personnel. Please explain “yes” answers on this page. No University of California, Division of Agriculture & Natural Resources 4-H Youth Development Program Waiver of Liability, Assumption of Risk, and Indemnity Agreement Participant’s Name (Please Print) County Club/Unit Waiver: In consideration of being permitted to participate in any way in California 4-H Youth Development 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 Youth Development Activities and Projects. Assumption of Risks: Participation in California 4-H Youth Development 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 the 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; and 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 Youth Development 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 Youth Development 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 Risk 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 or Adult Participant Date Age (if minor) THIS WAIVER APPLIES TO ALL CALIFORNIA 4-H YOUTH DEVELOPMENT ACTIVITIES AND PROJECTS INCLUDING, BUT NOT LIMITED TO PROJECT MEETINGS, CLUB MEETINGS, EDUCATIONAL FIELD DAYS, FIELD TRIPS, CAMPS, EXCHANGE PROGRAMS, FUNDRAISERS, COMMUNITY SERVICE ACTIVITIES, VOLUNTEER TRAININGS, FAIRS, AND PROJECTS. DRAFT AGENDA Meals will take place on campus except day of trip to Sequoia National Park. Tuesday, August 4, 2015 2:00 – 8:00 p.m. Arrive at Fresno between 2:00 p.m. and 8:00 p.m. Lodging at dorms available for participants – check in: 2:00 – 8:00 p.m. Pick up participants from airport 6:00 p.m. Supper provided if on campus at this time 8:00 p.m. Welcome activity/ice breakers & games led by participants Wednesday, August 5, 2015 7:00 a.m. Breakfast 8:00 a.m. – noon E.D.G.E. Challenge Course (low & high element team building ropes course) 12:00 p.m. Lunch 1:00 p.m. Session # 1 Leadership Skills/Teamwork/Communication 3:00 p.m. Group Photograph/Campus Tour/Bookstore Visit 4:00 p.m. Session # 2 Self-Assessment 5:00 p.m. Session # 3 Public & Private Value/Public Relations 6:00 p.m. Supper 7:30 p.m. Session # 3 Developing Your Story Thursday, August 6, 2015 7:00 a.m. Breakfast 7:30 a.m. Depart for Sequoia/Kings Canyon National Park – Sack lunch will be provided 6:00 p.m. Return to California State University, Fresno 6:30 p.m. approx. Supper Friday, August 7, 2015 7:00 a.m. 8:00 a.m. 10:00 a.m. 12:00 p.m. 1:00 – 3:00 p.m. 3:00 – 4:30 p.m. 4:30 – 5:15 p.m. 5:30 p.m. – 7:00 p.m. 7:30 p.m. Breakfast Session # 4 Public Speaking & Etiquette Session # 5 Telling Your Story Lunch Developing Ambassador Plan Sharing Ambassador Plans Final remarks and certificates Swimming Pool & Barbeque Recreation at the Student Union Saturday, August 8, 2015 7:00 a.m. Breakfast – Morning gathering and depart California State University, Fresno by 10:00 a.m. 2015 National 4-H Shooting Sports Youth Leadership Institute Application Form Name: Preferred First Name: Address: City: State: Home Phone Number: Zip: Cell Phone Number:_ Email Address: County: Club: Date of Birth: Years in 4-H: Grade in School: _ Age (as of Jan. 1 of current Year): _ Grade Point Average (GPA):_ _ List Local Newspaper/Media Outlet: Years in 4-H Shooting Sports (check those that apply): Archery Hunting Muzzle loading Pistol Rifle Shotgun The following information is to assure that any clothing ordered for you will fit properly. Polo Shirt Size: T-Shirt Size: 2015 National 4-H Shooting Sports Youth Leadership Institute Certification Form I will be active in my club and county 4-H program, as well as maintain an acceptable academic standard in school during my service as a 4-H Shooting Sports Ambassador. Further, I am willing to conduct myself in the highest standards expected of an Ambassador. Applicant’s Signature Date We (I) understand that our (my) son/daughter wishes to serve as a 4-H Shooting Sports Ambassador. We (I) will support him/her in fulfilling the responsibilities should he/she be selected. Parent/Guardian Signature Date Parent/Guardian Signature Date We certify that the above named 4-H’er is enrolled, active and in good standing in our 4-H shooting sports club and county 4-H program. We support his/her application for the position of 4-H Shooting Sports Ambassador. 4-H Club Leader Signature Date Extension Agent Signature Date State 4-H Shooting Sports Coordinator Signature Date: 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 of California, Agriculture and Natural Resources, 1111 Franklin Street, 6th Floor, Oakland, CA 94607, (510) 987-0096. National 4-H Shooting Sports Ambassador Program Guidelines National 4-H Shooting Sports Ambassador Program is designed to promote 4-H and 4-H Shooting Sports. Youth selected to serve as Ambassadors will receive training that will allow them to return to their homes and advocate for the program at the county, regional, and state level. Some Ambassadors may be asked to support national events as well. Ambassadors provide public relations support at special events such as donor/sponsor functions and also serve as spokespersons for the 4-H Shooting Sports Program, helping to make 4-H and the 4-H Shooting Sports Programs more visible. The Ambassador’s further develop their skills in leadership, public presentation, citizenship, community service, public relations and team building. PURPOSE, GOALS, OBJECTIVES The 4-H Shooting Sports Ambassador program will provide a venue for 4-H Teens to: 1. Represent 4-H and specifically 4-H Shooting Sports for public relations purposes at special events; at donor/sponsor functions and with the general public, 4-H groups, community service organizations, schools and media contacts. 2. Serve as spokespersons for the 4-H Shooting Sports program at their respective levels of participation – national, regional, state, county - helping to make 4-H Shooting Sports programs more visible. 3. Further develop their skills in leadership, public presentation, citizenship, community service, public relations and team building. 4. Assist in maintaining relations with 4-H Faculty and Extension Administrators as well as past, present and future program donors and supporters. 5. Continue and expand their involvement in 4-H Shooting Sports beyond the shooting skills and competitive events. 6. Stay actively connected with the 4-H Shooting Sports program as they enter their collegiate years and further into adulthood. PROGRAM EXPECTATIONS By being selected as a National 4-H Shooting Sports Ambassador, you will be representing over 320,000 4-H youth. What you say and do is very important. Remember, you never get a second chance to make a good first impression. As an Ambassador you may meet with donors who are CEO’s of companies or organizations and you always need to put your best foot forward. The way you dress, the way you speak and act are very important when you are serving as an Ambassador. • You are expected to be on time, so plan to be early to any event. • You need to respond promptly to any emails or phone calls from the Program Coordinator and your chaperon for the event. • It is very important that you send thank you notes immediately following the event. You will be given names and addresses so that you can fulfill this obligation. • You may get tired at events, but you always need to be cheerful and ready to respond positively to everyone. • A mature attitude and outlook is required. • Ambassadors may be asked by your State Shooting Sports Coordinator or the National Shooting Sports Committee to serve as a representative at a local, regional, state, or national event. BEHAVIORAL EXPECTATIONS A goal of the 4-H Shooting Sports Ambassadors program is to provide opportunities for youth to build character and develop their leadership skills. Ambassadors are expected to uphold the 4-H Code of Conduct at all times. DRESS CODE Ambassadors are expected to dress in a manner befitting young men and women. Modesty, neatness, well groomed and practicality will be the guiding principles. Attention to details is important, so here are some tips for both men and women. Make sure you have: • • • • • • • • • clean/serviceable shoes and a pair of sneakers and comfortable clothing for the ropes course well-groomed hairstyle cleaned and trimmed fingernails minimal cologne or perfume no visible body piercing beyond conservative ear piercings for women well-brushed teeth and fresh breath no gum, candy, or other objects in your mouth minimal jewelry no body odor Ambassadors are not to wear torn (intentional or otherwise) or sloppy clothing. Tank tops, muscle shirts, bare midriffs, low necklines, sundresses, and tight or otherwise revealing clothing will not be allowed. This applies to all spandex fashions. T-shirts with negative, outlandish, disrespectful messages or pictures will not be allowed. Also, you are representing 4-H shirts with the logos of other youth organizations should not be worn. Ambassadors are to have no visible tattoos. Ambassadors may wear shorts and skirts of modest style and length. Shorts, skorts and skirts may be no shorter than 3” above the knee. Females - Blouses/shirts must be tucked in when low-rise slacks/jeans/skirts/ are worn. Males – Casual or dress slacks should be worn with shirttails tucked in. All footwear should be clean, neat, shined and no flip flops. We will have one evening with a swim party. Swim suit standards for males is swim trunks only (no shorts, cut-off pants, or Speedos). Swim suit standards for females is one-piece suits are recommended; however, two-piece suits are allowed as long as they are modestly cut. No string, thong, or crochet suits will be allowed. When serving as a National 4-H Shooting Sports Ambassador, you need to remember that you are representing the 4-H Shooting Sports youth to the public and you need to make the best impression possible.
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