Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, genetic information, marital, family, or veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer.

If you are a person with a disability and desire any assistive devices, services or other accommodations to participate in these activities, please contact Dave Winston at (540) 231-5693/TDD* during business hours of 8:00 a.m. and 5:00 p.m. to discuss accommodations 5 days prior to the event. *TDD number is(800) 828-1120.

Join us for a fun-filled week!Tour cutting-edge farms, a state-of-the-art-greenhouse facility,

and former President James Madison’s historical home!

Test your nerve on some of the wildest rides on the east coast, enjoy retreat activities, and make new friends!

SundayGroups arrive in

afternoon

Cook out dinner at hotel

MondayBreakfast at hotel

Battlefield GreenhousesMarshalls Dairy

LunchMontpelier

DinnerTuesdayBreakfast at hotelCool Lawn Farm

LunchAl-Mara FarmCow N Corn

Dinner Barn Dance

WednesdayBreakfast at hotelKings Dominion

Dinner Evening activities

ThursdayBreakfast at hotel

Thanks for coming and have a safe trip home!

Round Hill Inn 750 Round Hill Road

Orange, VA 22960July 7-11

www.youth.dasc.vt.edu

2019 Southeast Dairy Youth Retreat July 7th - 11th

Orange, VA Youth Registration

Name __________________________________________________________________________ Address ____________________________________

___________________________________

___________________________________

Cell number of youth participant (if applicable): (_____)____________________________ Age (as July 1, 2019) __________ Male ______ Female ______ * Participants must be ages 9 – 19 to participate * Parent or Guardian: Name ______________________________________ Best number to reach by phone: (_____)__________________________ Name of adult chaperone(s) while at retreat, if known. T-Shirt Size (please circle): S M L XL XXL Name of person(s) you wish to room with (there will be 4 youth per room):

1. __________________________________________

2. __________________________________________

3. __________________________________________

REGISTRATION AND PAYMENT DUE BY JUNE 1ST, 2019

1. 10.

2. 11.

3. 12.

4. 13.

5. 14.

6. 15.

7. 16.

8. 17.

9. 18.

Payment Form

Please mail this form along with your payment to: University of Georgia c/o Dr. Jillian Bohlen

Rhodes Center for Animal and Dairy Science 425 River Rd.

Athens, GA 30602

Deadline: June 1st, 2019 Make checks payable to “GA 4-H Foundation” with “SEDYR” in the memo line Registration Fee - $240 per person

County Coordinator Information (FFA Advisor or Extension Agent):

Name _________________________ E-mail: _______________________

Phone: _______________________ Signature _____________________

Participants (youth):

Publication 4H-164NP

www.ext.vt.eduProduced by Communications and Marketing, College of Agriculture and Life Sciences, Virginia Polytechnic Institute and State University, 2016

Virginia Cooperative Extension programs and employment are open to all, regardless of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, genetic information, veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State

University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; M. Ray McKinnie, Interim Administrator, 1890 Extension Program, Virginia State University, Petersburg.

VT/0416/4H-609NP

*18 U.S.C. 707

*

2

www.ext.vt.edu

GEORGIA 4-H CODE OF CONDUCT

BEHAVIOR STANDARDS The Georgia 4-H Code of Conduct is valid for one year and applies to all activities coordinated through Georgia 4-H.

4-H’ers are expected to attend all sessions as part of a planned program exhibiting positive character and behavior including (but not limited to) trustworthiness,responsibility, respectfulness, caring, citizenship and fairness.

4-H’ers are expected to be responsive to the reasonable requests of leaders and respectful of the needs for their personal safety and the safety of others.

4-H’ers should dress appropriately, use appropriate language and respect the rights of others.

4-H’ers may not behave recklessly or in a manner which prohibits others from participating in the program in the manner intended.

4-H’ers may have access to technology at UGA/CES offices and facilities. Technology use is for educational purposes. 4-H’ers may not access inappropriate websites or materials.

Realizing these guidelines are not “all inclusive” the University of Georgia Extension staff and volunteers reserve the right to make adjustments to these policies.

CONSEQUENCES OF MISBEHAVIOR 4-H’ers and adults who observe a breach in the Code of Conduct must report the misbehavior to the appropriate leader. The leader will complete an incident report and determine the next steps regarding the incident.

If 4-H’ers are found participating in actions listed below, law enforcement or other legal authorities may be notified and may lead the review and consequences related to the incident. In these incidents, 4-H’ers may be removed from the event and suspended or expelled from future 4-H participation. These behaviors may include, but are not restricted to:

Possession or use of illegal drugs

Possession or use of a weapon

Assault or harassment

Inappropriate sexual behavior

If the 4-H’er is found participating in the actions listed below, 4-H leaders may be notified and may lead the review and consequences related to the behavior. 4-H’ers misbehaving will have the opportunity to explain their actions to leaders in charge of the activity and may request a review board. The person coordinating the event may also convene a review board for the purposes of determining what has occurred and what disciplinary action should be taken. A review board will consist of one Extension faculty or staff member, two volunteers and three 4-H members. The Extension faculty member coordinating the event will serve as chairperson. In some cases, incidents are deemed serious and may be referred to law enforcement or other legal authorities.

If the 4-H’er receives consequences from the leader or through the review process, his/her parents/guardians may be notified; the 4-H’er may be sent home at the parents’ expense and may be suspended from participation in 4-H events. Suspensions may be up to one year. If a 4-H’er wishes to appeal the decision of the review board, the 4-H’er must appeal in writing through the County Extension office. Appeals must be filed within 10 days of notification of the disciplinary action. The appeal is sent to the Program Development Coordinator of the 4-H member and the State 4-H Leader for ruling by the State 4-H Leader. Following any disciplinary review, the person coordinating the activity will provide written notification to the appropriate parties including but not limited to the 4-H’er, his/her parent/guardian and his/her county Extension faculty member.

Breaking curfew or disturbing the peace

Unexcused absences from the activities or premise of an event

Unauthorized use of vehicles during the event

Reckless or inappropriate behavior

Use of foul or offensive language

Possession or use of alcohol or tobacco

Breach of the 4-H Code of Ethics

Remaining in the presence of those who are breaking the 4-H Code of Conduct

Theft, misuse or abuse of public or personal property

Possession of fireworks

PARENT/GUARDIAN & 4-H’er AGREEMENTS Release Waiver of Liability and Covenant Not to Sue I have read the Georgia 4-H Code of Conduct and agree to participate fully in all aspects of program activities. I understand the standard of behavior and agree to maintain such during 4-H programming.

____________________________________________________________________ ____________________ 4-H’ers Signature Date

I have reviewed the Code of Conduct and agree to all of its provisions. For the sole consideration of the Cooperative Extension Service’s arranging for participation in 4-H programming, I hereby release and forever discharge The University of Georgia, the Board of Regents of the University System of Georgia, their members individually, and their officers, agents and employees from any and all claims, demands, rights and causes of action of whatever kind that I may have, either on my own behalf or in my capacity as a legal representative of my child, arising from or in any way connected with my child’s participation in 4-H. I further covenant and agree that for the consideration stated above I will not sue the Institution, the Board of Regents of the University System of Georgia, its members individually, its officers, agents or employees for any claim for damages arising or growing out my child’s participating in the program. I understand that the acceptance of this Release, Waiver of Liability, and Covenant not to sue the Board of Regents of the University System of Georgia shall not constitute a waiver, in whole or part, of sovereign immunity by said Board, its members, officers, agents, and employees. I certify that my child is participating in 4-H with my knowledge and consent. I have read and understand all of the above

policies. I hereby grant permission my child’s images, likeness, and voice to be recorded in any media during this program and to be used by the University of Georgia and Georgia 4-H on behalf of the Board of Regents of

the University System of Georgia in any publications, media, or technology now known of or hereby developed in the future for any lawful purpose whatsoever without further permission from me. I understand I will not be compensated further for use of these recordings.

_____________________________________________________________________________________ __________________ Parent/Guardian Signature Date Phone

VALID FOR ONE YEAR FROM DATE OF SIGNING Revised 6/2016

4-H’ers Name:_________________________________________________________County________________________________

Address:______________________________________________________________Phone________________________________

School:_______________________________________________________Grade:_____________________Year:_______________

4-H Health HistoryReport form

Publication 388-906Reviewed 2016

INSTRUCTIONS: Please provide detailed health information for determining appropriate supervision, support, and accommodations for the 4-H activity or event listed. A parent or guardian must sign. If the participant is a person with a disability and desires any assistive devices, services or other accommodations to participate in this activity, please contact your local Extension office during business hours at least 7 days prior to the event to discuss accommodations. PLEASE PRINT ALL INFORMATION. (NOTE: Both sides of this form must be completed.)

Name of 4-H event in which you wish to participate: __________________________________________________________________

Date(s) of event: _________________________________ Location: ___________________________________________________

PARTICIPANT IDENTIFICATIONName: _________________________________________________________________________________ Female: ■ Male: ■

Last First (Underline name by which you like to be called) Middle

Mailing address: _____________________________________________________ Participant cell phone: ( ______ ) _______________

City: ____________________________ State: _____ ZIP: _____________ Home phone: ( _______ ) _____________________

Age: __________ Birthdate: ___________________ Home email: _______________________________________

Ethnicity (choose one): Hispanic/Latino ■ Not Hispanic/Latino ■

Race (choose all that apply): American Indian/Alaskan Native ■ Asian ■ Black/African American ■Native Hawaiian/Other Pacific Islander ■ White ■

PARENT / GUARDIAN IDENTIFICATION (Place a check beside who to reach in the event of an emergency.)

■ First parent/guardian name: ________________________________ First parent/guardian email: ___________________________

First parent/guardian phone daytime: _____________________ Evening: ____________________ Cell: _____________________

■ Second parent/guardian name: ______________________________ Second parent/guardian email: __________________________

Second parent/guardian phone daytime: _____________________ Evening: ______________________ Cell: _________________

Who has primary custody of the participant? ________________________________________________________________________

Address, if different than child: ____________________________________________________________________________________

PHYSICIAN / INSURANCE INFORMATIONFamily physician name: _________________________________________________

Phone: ( ________ ) _________________________

Dentist/orthodontist name: __________________________________________ Phone: ( ________ ) _________________________

Do you carry family medical / hospital insurance?: Yes ■ No ■Carrier: ______________________________________________ Policy ID #: _____________________________________________

EMERGENCY CONTACT INFORMATION (Parts 1 and 2 should be completed)1. Where can you be reached in the event of an emergency?

Location:___________________________________________________________

Phone: ( ______ ) __________________________

Cell phone: ( ______ ) _____________________

2. If you Cannot be reached, who should be notified?Name: ____________________________________________________________

Home phone: ( ______ ) ____________________

Work phone: ( ______ ) ____________________

Cell phone: ( ______ ) _____________________(continued on back)

(Check ✔ one)

4-H PARTICIPANT MEDIA RELEASE

The Virginia Polytechnic Institute and State University/College of Agriculture and Life Sciences (CALS) periodically uses electronic and traditional media (e.g., photographs, video, audio footage, testimonials) for publicity and educational purposes. By my signature on this form, I acknowledge receipt of this document and give permission to the College of Agriculture and Life Sciences and its designee to use such reproductions for educational and publicity purposes in perpetuity without further consideration from me.

I understand that I will need to notify Virginia Tech/College of Agriculture and Life Sciences if any changes to my situation occur that will impact this media release permission.

■ Yes ■ No

www.ext.vt.eduProduced by Communications and Marketing, College of Agriculture and Life Sciences, Virginia Tech, 2016

Virginia Cooperative Extension programs and employment are open to all, regardless of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, genetic information, veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S.

Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; M. Ray McKinnie, Interim Administrator, 1890 Extension Program, Virginia State University, Petersburg.

VT/1016/4H-696NP

* 18 U.S.C. 707

www.ext.vt.edu

PARTICIPANT HEALTH AND MEDICAL HISTORY (Questions 1-5 must be completed.)

1. SPECIAL DIETARY NEEDS

INSTRUCTIONS: The purpose of this section is to communicate special dietary needs,food allergies, etc. for any child, teen, or adult who will be attending a 4-H event.

In the space below, please list all food allergies and/or other dietary restrictionsfor the person listed above and any necessary precautions that should be taken:__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

2. Has the participant ever experienced (or had special needs in) any of the following?[Check (✔) all that apply]

■ Asthma ■ Bleeding disorders ■ Attention disorders (ADHD)■ Eating disorders ■ Seizures/Convulsions ■ Wears contacts■ Diabetes ■ Bed Wetting ■ Behavior■ Fainting spells ■ Non-food allergies ■ Other: ___________________

Please describe any condition or need that you checked: ___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

3. Is the participant experiencing any current health problems, under medical care,receiving mental or behavioral services, or currently taking medication?

■ YES ■ NO If YES, please explain: _____________________________________________________________________________________________________

4. Has the participant undergone surgery, or experienced any injury, illness, allergy,or change in health status any time during the last year? Is there any reason thatparticipation in a program or activity should be restricted?

■ YES ■ NO If YES, please explain: __________________________________

___________________________________________________________________

5. What else should we know about your child?

4-H programs include very rewarding, but sometimes challenging situations. Pleaseinform us of any concerns that may arise related to your child’s physical, mental,emotional, and/or social health in order that we may better provide appropriatesupervision and support.__________________________________________________________________________________________________________________________________________________________________

RELEASE AUTHORIZATIONI give permission to the following individual(s) to pick up my child at the conclusion of this 4-H event:

Name(s): ________________________________, ________________________________, _______________________________Sign below at time of pick up (Receiving person must be pre-listed above):Name (print): _______________________________ Signature: _______________________________ Date: ________________

APPROVAL / EMERGENCY AUTHORIZATION

(Please read parts 1 and 2. If the participant is under 18, parents/guardians must sign in the space provided. If you are over the age of 18, please sign for yourself. If you can-not sign this due to religious reasons, you must contact your Extension office to obtain a legal waiver that must be signed. If this section is not signed, participation in the 4-H event/activity will not be allowed. You must contact your Extension office if there is a change in health status after submitting this form.

1. I give my permission for the participant named on thisform to attend the designated 4-H program. He / Shehas permission to participate in all activities which mayinclude swimming and other water sports under thesupervision of lifeguard(s) and to take part in other sched-uled activities such as firearm safety, horsemanship,archery, low ropes, physical activity/exercise and relatedactivities under the supervision of instructors; subject tolimitations noted herein.

2. I hereby give permission to the medical staff personselected by the event/activity director to order X-rays, rou-tine tests and treatment for my child (or for myself if I ama participant over 18 years old) as medically necessary.I also give permission for the participant to receive over-the-counter medication as needed under the guidance ofthe medical staff person. I understand that all attemptswill be made to notify parents/guardians of any seriousinjury or illness to their child. If I cannot be reached in anemergency, I hereby give permission to the medical staffperson to hospitalize, secure proper treatment for, and toorder injection and/or anesthesia and/or surgery for me/or the participant named on this form. This form may bephotocopied for use outside of the event/activity location.

ADULT PRINTED NAME:

________________________________________________

SIGNED: X______________________________________ (Parent / Legal Guardian or participant over 18 years old)

Date: _______________________

I understand and agree to abide with any restrictions placed on my activities according to this form.

YOUTH PRINTED NAME:

________________________________________________

SIGNED: X______________________________________ (Participant under 18 years old)

Date: _______________________

IMMUNIZATION HISTORY (This must be completed)

Are your child’s immunizations up to date? ■ YES ■ NO Date of most recent tetanus shot: (month/year) _______/_______

www.ext.vt.eduProduced by Communications and Marketing, College of Agriculture and Life Sciences,

Virginia Polytechnic Institute and State University

Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Mark A. McCann, Director, Virginia Cooperative Extension, Virginia Tech,

Blacksburg; Alma C. Hobbs, Administrator, 1890 Extension Program, Virginia State, Petersburg.

VT/0109/W/388036

REVISED 2009 PUBLICATION 388-036

4-H Form

* 18 U.S.C. 707

4-H Event Medication FormINSTRUCTIONS: Please complete this form for all medication(s) your child will be taking as needed, including over-the-counter medications for headaches or cold, inhalers, etc.

NOTE: This form must accompany your child to the 4-H event only if he/she is taking any medication. Please read the following information related to the “Medication Policy.” Your signature below indicates that all information provided on this form is correct and you understand the 4-H center medication policy.

Medication Policy

3 Youth under 18 years old will not be allowed to keep ANY medicines with them.3 All medications submitted at the 4-H event registration must be in the ORIGINAL CONTAINER with the

youth’s (or teen’s) name printed on the bottle. 3 Zip-lock bags, other bottles, bottles printed with someone else’s name, or any other type of container besides

the original, will not be accepted. 3 Actual dosage listed on the bottle must be followed unless there is a written note from the prescribing doctor

outlining different indications.

THERE WILL BE NO EXCEPTIONS TO THIS POLICY.

I have read and understand the above policy.

Parent/Guardian initials: Date:

Member’s Name:

Parent/Guardian Phone: (Day) (Evening)

Medication Name (include any special insturctions)

As Needed

Break-fast Lunch Dinner Bedtime

FOR ADDITIONAL MEDICATIONS ATTACH ADDITIONAL COPIES OF THIS PAGE.

Medication Release (Do not sign this line until you pick your child up from the event.)

My signature below indicates that I have picked up all medications from the 4-H staff person following the comple-tion of the 4-H event.

Parent/Guardian Signature: Date:

2019 Southeast Dairy Youth Retreat

Items necessary for a complete registration packet:

Registration Form ☐

Payment Form ☐

VA Code of Conduct ☐

GA Code of Conduct ☐

VA Health History ☐

VA Medication ☐

Payment ☐

A g r i c u lt u r e A n d n A t u r A l r e s o u r c e s • FA m i ly A n d c o n s u m e r s c i e n c e s • 4 - H y o u t H

An equal opportunity/affirmative action institution

georgia4h.org

Dr. Jillian Bohlen Animal and Dairy Science Department 425 Rhodes Center for Animal and Dairy Science Phone: 706-542-9108 E-mail: jfain@uga.edu

May 14th, 2019 4-H Agents, FFA Advisors, Youth Leaders and Parents,

The 2019 Southeast Dairy Youth Retreat is scheduled for July 7th – 11th in Orange, VA. This annual event is a tremendous opportunity for youth ages 9 to 19. During the retreat, youth participants from seven southeastern states will interact with dairy industry professionals during hands-on learning activities. This year’s group will visit a wide variety of farms from dairy to large-scale greenhouses while getting involved in a number of interactive workshops! The group will also make an outing to Kings Dominion and have dinner at Montpelier! This looks to be an incredible schedule of activities. The cost is $240 per youth participant and includes lodging (4 youth per room), events, most meals, travel, and chaperones. Group transport will be arranged by UGA Extension and will depart from Athens, GA on Sunday. You will be provided more information following receipt of your registration materials. We are looking for young people from Georgia to attend this tremendous event where they will gain a greater understanding of the dairy industry while building long lasting friendships in agriculture! Please distribute information to your youth members and let me know if you have any questions. Please visit the URL below to find all forms and information regarding the 2019 retreat. https://site.extension.uga.edu/dairy/ Registration materials (forms and payment) are due by June 1st, 2019. On the payment form, you will see that contact information is REQUIRED for the “county coordinator”. This person will be contacted to verify registrants. Each youth registrant MUST have the signature (recognizing support of youth member) of a county coordinator. The county coordinator may be an Extension Agent or FFA Advisor.

If you have any trouble with the link, please e-mail me at the address above and I will get you to the correct forms. I hope that youth from your county will take advantage of this tremendous event! There are few others offered that are anything like it. As a final note, we will need chaperones. If interested in chaperoning the event, please contact me directly via e-mail to jfain@uga.edu. For all approved chaperones, the cost of lodging and registration will be covered thanks to the generous support of Georgia Dairy Youth Foundation and Southeast Milk Check-off. If you have any questions, please do not hesitate to contact me. Sincerely,

Jillian Bohlen, Ph.D. Assistant Professor and State Dairy Extension Specialist