Sponsored by Rutgers Cooperative Extension of Bergen, Essex, Morris and Passaic Counties,

and made possible by a grant from The Wal-Mart Foundation and National 4-H Council.

The 4-H Youth Development Program is part of Rutgers New Jersey Agricultural Experiment Station Cooperative Extension. 4-H educational programs are offered to

all youth, grades K-13, on an age-appropriate basis, without regard to race, religion, color, national origin, ancestry, sex, sexual orientation, gender identity and

expression, disability, atypical hereditary cellular or blood trait, marital status, civil union status, domestic partnership status, military service, veteran status, and any

other category protected by law. For additional information, contact: 973-684-4786 or nj4h.rutgers.edu.

When: Friday, April 17th— Saturday April 18th

8 PM—8 AM

Register by April 9th!

4-H Youth in Grades 6-8 are invited to attend this overnight event on April

17th –18th. This year’s theme is LIVING

STRONG: Learn how to be the best version of you

through healthy living activities, team building

games, friendly competitions and

opportunities to learn and practice leadership

skills.

Register Early Space is Limited! Have Questions? Contact the Passaic

County 4-H Office at passaic4H@njaes.rutgers.edu

The event will be held at the Essex County Environmental Center in Roseland, NJ

Cooperative Extension of Passaic County

4-H Youth Development Program

1310 Route 23 North

Wayne, NJ 07470

Phone: 973-684-4786

Fax: 973-305-8865

Passaic4h@njaes.rutgers.edu

The Northern Jersey 4-H Super Cool Middle School Youth Overnight

“Live Strong”

This year the Northern Jersey 4-H counties are hosting and overnight sleepover event focused on eating healthy, being active and having fun. 4-H youth in grades

6th through 8th are encouraged to participate in this fun event that is sure to get kids thinking more about their health in a positive way.

Cost $10.00 per youth. Please make checks payable to the Essex County 4-H Leaders

Association.

Event Location

This event is at the Essex County Environmental Center at 621 Eagle Rock Ave, Roseland, NJ 07068

What to bring Sleeping bags, pillows, etc. Pajamas/change of clothes.

Lots of energy!

What to wear

Participants should wear comfortable clothing to be active in; sweatpants, T-shirts, and sneakers are recommended.

Event rundown Registration will begin at 8:00PM

Activities and programs will run from 8:30PM to 2:30AM Sleep/quiet time will be from 2:30AM – 7:00AM Breakfast and evaluations at 7:00AM

Parent pick-up at 8:00AM All food is provided, if you child has an allergy please indicate on attached health

form we will accommodate.

Participants must have all attached forms filled out and signed (in this packet:

event permission form, health form, liability form and parental consent form). If you have questions please contact the Passaic County 4-H office.

Please send all completed registration materials to the Passaic County 4-H office 1310 Route 23 North Wayne, NJ 07470

FAX: 973-305-8865

PHONE: 973-684-4786 EMAIL: passaic4h@njaes.rutgers.edu

Registrations are due April 2nd

New Jersey 4-H Event Permission Form for Youth

4H104

Both sides of this form must be completed by all youth participating in overnight activities, field trips, events requiring group transportation, and any other events sponsored through the 4-H Youth Development Program where it is deemed necessary by the event coordinator(s) (paid 4-H staff and/or registered 4-H volunteer) responsible for the youth participants. The form should be submitted prior to the event. The form has five parts: (1) information about the participant and activity, (2) parental permission and liability release, (3) medical emergency authorization and health information, and (4) code of conduct and (5) media policy. Be sure to complete all five parts and sign where requested!

Information about the Youth Participant and Activity Name of Youth participant: ____________________________________________________________________________________

Address: _______________________________________________ City:__________________ State:_______ Zip:__________

Telephone number: _____________________________________ Email Address: ___________________________________

4-H county: ____________________________________________ Birthdate: ____________________ Grade: _______________

Name of activity/event: _______________________________________________________________________________________

Name of 4-H group sponsoring or participating in this event: __________________________________________________________

Location of event: ___________________________________________________________________________________________

Date and time of participation of individual named above: ___________________________________________________________

Parent Permission and Release of Liability

I hereby give my son/daughter named above permission to participate in the event listed. Although Rutgers Cooperative Extension and its event coordinator(s) will use the utmost precaution in guarding the health of the above participant and preventing accidents, I release them from any liability in case of illness or injury as a result of this activity. Furthermore, I release the owner and driver of the car transporting my child to and from the event, from any liability in case of illness or injury.

Signature of parent or guardian: _________________________________________________________________

Medical Emergency Authorization and Health Information

I authorize the event coordinator(s) to dispense the prescription drugs and/or over the counter medications listed below in accordance with the instructions provided on the label (prescription drugs) or below (over-the-counter medications). In case of sudden illness or an accident to the above named participant requiring immediate treatment or surgery while he/she is a participant in this activity, I authorize the 4-H chaperone(s) to take such action as seems appropriate to protect the health and physical well-being of the above participant. This authority extends to any physician(s) and/or surgeon(s) selected by the event coordinator(s) to perform medical and/or surgical procedures including examinations and tests necessary to preserve the health and physical well-being of the above named participant. All efforts will be made to contact the parent(s) or guardian(s) in case of emergency. ____________________________ ____________________ __________________________________ __________________ Name of parent/guardian Phone number Name of additional emergency contact Phone number

The following information is provided as an aid to the event coordinator(s) in dealing with the well-being of the participant. The participant has the following health conditions: (include allergies, handicaps, diabetes, pregnancy, asthma, medications needed, etc.).

Health conditions: ___________________________________________________________________________________________

Medications/Instructions: _____________________________________________________________________________________

Health Insurance: Company Group# ___________________________________ ID# _____________________________________

Signature of parent or guardian ________________________________________________________________

Continued on other side

Sign Here

Sign Here

New Jersey 4-H Code of Conduct The primary purpose of the New Jersey 4-H Code of Conduct is to ensure the safety and well-being of all participants at 4-H sponsored events and activities. It applies to all participants, with participants defined as 4-H members, their parents, and volunteers. As a participant in the 4-H program, I will: • Conduct myself in a courteous manner and treat members, parents, 4-H volunteers, Extension staff, judges and

others with respect. Appropriate language and behavior are expected at all times. • Respect and adhere to the rules and guidelines of the 4-H program including all those specific to a 4-H event or

activity.

• Uphold an individual’s right to dignity by supporting an environment of inclusion which welcomes involvement of participants from all backgrounds.

• Accept supervision and support from county and state 4-H staff while participating in the 4-H program. This

includes acceptance of supervision and support from appointed 4-H volunteers coordinating 4-H events and activities.

• Obey local, state and federal laws. Participants who fail to adhere to the New Jersey 4-H Code of Conduct are subject to a range of disciplinary actions. Such actions will be taken in compliance with the New Jersey 4-H Discipline Policy and Procedure. When appropriate, immediate corrective action will be taken at the 4-H event to ensure the safety and welfare of all participants.

I understand if I fail to adhere to the above Code of Conduct, I will be subject to disciplinary action and potentially prohibited from attending and participating in the New Jersey 4-H Youth Development program.

_______________________________________________________ ____________________________________ Signature of participant in event Date

_______________________________________________________ ____________________________________ Signature of parent or guardian Date

New Jersey 4-H Media Policy and Release The 4-H program routinely promotes activities through various media. This includes, but is not limited to newsletters, newspapers, brochures, and displays. In doing so, the names and photos of members may be included to help tell the 4-H story. However, New Jersey 4-H policy is that on web sites, youth in photos will not be identified by name(s).

❑ No, do not use my individual picture for any purpose. I will make an effort to avoid opportunities to be in group photos.

❑ No, do not use my name for any purpose. Revised: January 2013

Sign Here

Sign Here

Rutgers Cooperative Extension Health Form

2015

Name

Street Address

City Zip Code

Cell Phone Home Phone

Father’s Name Day/Cell Phone

Mother’s Name Day/Cell Phone

Health Insurance Provider Number

In case of illness, etc., list alternates in the area other than father and mother to be called:

Name Phone No. Cell Phone

Name Phone No. Cell Phone

Name Phone No. Cell Phone

Doctor Phone No.

Current Health Information:

Have you been sick, hurt, hospitalized since January 2010? Yes No

Describe, Date & Treatment

Date of last Tetanus Shot

List all food allergies

List all other allergies (including Latex)

Can your child participate in all activities? Yes No

If any restrictions, please forward a doctor’s statement to the nurse along with this form.

Date

Parent or Guardian’s Signature

RCE of Salem County

51 Cheney Rd., Suite 1

Woodstown, NJ 08098

Phone: 856-769-0090

Fax: 856-769-1439

www.njaes.rutgers.edu

PARENTAL INFORMED CONSENT FORM

Identification of Project: 4-H Youth Voice: Youth Choice

Purpose of the Research:

The goals of this assessment include: (1) To obtain data on 4‐H youths’ outcomes related to

Positive Youth Development and Healthy Living; and (2) To obtain annual data that will assess the

National 4‐H program’s progress in achieving the outcomes established in each of the previously

mentioned areas. The overall purpose is to inform and improve the replication of 4-H programming.

Procedures:

Your child will complete the survey following or during their participation in a 4--H Program. Youth will

take the survey which is approximately 15-20 minutes in length. Youth will complete paper copies which

the on-site facilitator will supply. The on-site facilitator will send paper copies to the Investigator for

entry. Copies will be stored in a secure location until the study is complete and then destroyed.

Risks and/or Discomforts:

There are no known risks or discomforts associated with this research.

Benefits:

The information gained in this study will help improve future 4-H healthy living programs and provide

4-H with insight to the trainings/procedures necessary to improve future programs.

Confidentiality:

No information obtained in this study will identify an individual child. The data will be stored in a secure

location at the offices of the investigating teams and on a secure server and will only be seen by the

investigators and the managers of the online site during the study. The information obtained in this study

will be analyzed and reported as aggregated data.

Compensation:

There will be no compensation for participating in this study.

Opportunity to Ask Questions:

You may ask any questions concerning this research and have those questions answered before agreeing to

participate in or during the study. Or you may call the investigator at my office phone, 856-769-0090.

Freedom to Withdraw:

You are free to decide not to participate in this study or to withdraw at any time without adversely

affecting your relationship with the investigators, Rutgers University or 4-H Youth Development. Your

decision will not result in any loss or benefits to which you are otherwise entitled.

Consent, Right to Receive a Copy:

YOU ARE VOLUNTARILY MAKING A DECISION WHETHER OR NOT TO ALLOW YOUR

CHILD TO PARTICIPATE IN THE RESEARCH STUDY. YOUR SIGNATURE CERTIFIES

THAT YOU HAVE DECIDED TO ALLOW YOUR CHILD TO PARTICIPATE HAVING READ

AND UNDERSTOOD THE INFORMATION PRESENTED.

___________________________________________

Child’s Name

___________________________________________ ______________

Signature of Parent Date

IN MY JUDGEMENT THE PARENT/LEGAL GUARDIAN IS VOLUNTARILY AND

KNOWINGLY GIVING INFORMED CONSENT AND POSSESSES THE LEGAL CAPACITY

TO GIVE INFORMED CONSENT TO PARTICIPATE IN THIS RESEARCH STUDY.

6-17-2013

___________________________________________ _______________

Signature of Investigator Date

INVESTIGATOR

Annette Devitt

RCE of Salem County

51 Cheney Rd., Suite 1

Woodstown, NJ 08098

ESSEX COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER

County of Essex Environmental Center

WARNING, WAIVER, AND RELEASE OF LIABILITY

DATE: In consideration of being given permission to participate in the:

(the “Event”) on

(date[s]) supervised by I hereby waive, release and discharge any and all claims for damages for death, personal injury or property damage which I may have, or which hereafter accrue to me, against the County of Essex or the Essex County Environmental Center as a result of my participation in the above listed Event. I realize that accidents and injuries can arise out of the Event, and accordingly, this release is intended to discharge the County, its trustees, officers, employees, commission members, and volunteers, and any public agencies from and against any and all liability arising out of or connected in any way with my participation in the Event. This waiver and release is binding upon my heirs and assigns. I acknowledge that I have been fully informed of the risks and dangers involved in this activity. I acknowledge that I have read, agree, and fully understand the above Warning, Waiver, and Release of Liability. I further acknowledge and agree that the reasons for my being requested to sign this Release have been fully explained to me and I understand them. If any provision, including any exception, part, phrase, or term, or the application thereof to any person or circumstance is held invalid, the application to other persons or circumstances shall not be affected thereby and the validity of this waiver in any and all other respects shall not be affected thereby. I am signing this instrument of my own free will and I have not been influenced or coerced by any representative or employee of the County of Essex or the Essex County Environmental Center: SIGNATURE DATE If signatory is less than 18 years of age, this must also be signed by a parent or guardian. PARENT/GUARDIAN SIGNATURE DATE WITNESS (Leave this line blank for Essex County Environmental Center Staff) DATE Please forward signed copies of this waiver form to: Risk Management Office of the County Administrator Hall of Records – Room 510 465 Dr. Martin Luther King Jr. Blvd. Newark, NJ 07102