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1303 17th Street West
Palmetto, FL 34221
Telephone: 941.722.4524
4-H Fax: 941.721.6744
Main Fax: 941.721.6608
April 15, 2015
TO:
4-H Youth Eligible to Participate at 4-H Junior Residential Camp
FROM:
Diana L. Smith, Ph.D.
4-H Coordinator
RE:
4-H Junior Residential Summer Camp, June 8-12, 2015
Camp Cloverleaf, Lake Placid
Angelita Ortiz
4-H Program Specialist
Spring is already upon us and the end of the school year fast approaching, which means that 4-H JUNIOR RESIDENTIAL
SUMMER CAMP will be here before we know it. We have selected an exceptional group of youth to serve as counselors, and they
are excited and ready to get started with their plans for camp. The Manatee County 4-H Camp Committee is working hard to
plan another fun-filled week. We hope that all 4-H'ers between the ages of 8 and 12 are planning to attend this summer's camping
session. Remember, in order to attend youth must be 8 -12 years old as of September 1, 2014.
REGISTRATION PACKETS FOR ALL CAMPS AND PARTICIPANTS ARE DUE TO THE 4-H OFFICE
ON OR BEFORE MONDAY, May 4, 2015 BY 5:00 PM
Registration Packets can be mailed to the 4-H Office at:
1303 17th St W, Palmetto FL 34221 or hand delivered to the 4-H Office at the Fairgrounds in Palmetto.
Camper space is limited, therefore enrollment will be available on a first-come, first-served basis.
Camp registrations will be date/time stamped upon receipt.
Camper, Parent, Family Member, or Leader may register youth for camp.
All Counselors, CIT2, CIT/Leadership Track, Adult Volunteers and Campers will need
to submit all necessary paperwork and fee payment as indicated.
Parent orientation for camp is scheduled for Tuesday, May 19th at 7:00 pm @ the 4-H Center
Attendance is highly recommended for campers and parents.
Again this year, campers are invited to ask a “buddy” to attend camp with them. A “buddy” is a friend who is the same gender and
the same age, or within a year of your age AND must be 8 -12 years old as of September 1, 2014. Buddies are not eligible for
any 4-H scholarships but may be eligible for the Meal Benefits summer food program. Buddies may be eligible for a special Parrish
Foundation buddy scholarship if they live in the Parrish community.
Please read the camp packet in its entirety. Questions and Answers about Summer Camp will provide all the camp details. There are many
areas or forms to be completed that are included in this letter. It is a lot, but should make the camping application process easier. Descriptions of
the application forms are on the following pages.
The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity Institution authorized to provide research, educational information, and
other services only to individuals and institutions that function with non-discrimination with respect to race, creed, color, religion, age, disability, sex, sexual
orientation, marital status, national origin, political opinions, or affiliations.
DESCRIPTIONS OF CAMPER APPLICATION FORMS
CAMPER REGISTRATION - The registration form gives the 4-H Office pertinent camper information at a glance. Please check
it over a couple of times to be sure all questions are answered and boxes checked. The entire camper registration packet (with
registration fees) is due back to the 4-H Office no later than 5:00 pm, MONDAY, MAY 4, 2015. Checks should be made payable
to Manatee County 4-H Foundation.
CAMP FINANCIAL SHEET - This sheet will make figuring your camp fees easier. If the camper is receiving a 4-H scholarship,
be sure to note if it is a club awarded scholarship (paid by your 4-H Club and requested from your leader) or a county awarded
scholarship (paid by the Manatee County 4-H Foundation and also requested through your 4-H leader). Scholarship applications
must be in the 4-H Office by April 6, 2015 and signed by the 4-H Club Organizational Leader for youth to deduct a scholarship
amount from the camp fee. The Manatee County 4-H Fee Payment Policy Applies.
CAMPER PICK-UP/DROP-OFF INFORMATION - This information will confirm where the camper will be getting on the bus
to go to camp and getting off the bus coming home from camp - Once this information has been submitted, PLEASE do not
request changes. It is very difficult and confusing for the 4-H Staff, counselors, campers, and camp coordinator to make sure the
camper and their luggage, is where the parent will be. It is necessary for each bus driver to have a list of all youth, their addresses,
ages, and emergency contact numbers before the child can board the bus. If last minute changes are made, it is possible for the bus
driver to refuse to allow the camper to board.
ZERO TOLERANCE CELL PHONE OR ANY ELECTRONIC DEVICE POLICY – This is an unplugged camp. Manatee
County 4-H will enforced zero tolerance cell phone or any other electronic devices policy. Please do not allow your camper,
counselor, CIT or CIT/ leadership participant to bring a cell phone or electronic device to camp. Counselors will be allowed radios
and an alarm clock (one per cabin). If you are found to have a cell phone or other electronic device you will go home immediately.
Manatee County 4-H will not be responsible for lost or damaged items.
GRAFFITI/PROPERTY DAMAGE POLICY – Issued by the State 4-H Office, this policy is to protect the camp facilities as
well as the camp participant and must be signed before the registration packet is considered complete. We hope our 4-H members
will want to take very good care of 4-H Camp Cloverleaf making this policy just a formality.
SICKNESS POLICY – If your child becomes ill during their stay at camp, please note that we will be using the same policy as the
Manatee County School Board. If your child, is vomiting or running a fever, you will be asked to come pick them up.
SUMMER FOOD MEAL SERVICE PROGRAM - The meal benefit form for summer food service (USDA Summer Food
Program) must be returned with the camp registration packet. If you do not qualify, write “declined” across all pages of the
application. If you do qualify, please complete the form (make sure you fill in your Case #.) If you need assistance, call the 4-H
Office at 941.722.4524. This program is being offered through the federal government as a means of financial aid for qualified
families. Everyone (camper, counselor, CIT and CIT/leadership participant) even if you/they are not receiving a
scholarship they must submit this form with their registration packet!
SPECIAL DIETARY NEEDS FORM – This special needs form is to provide essential information about the camp participant’s
food allergies or restrictions. The camp staff will make every effort to accommodate these needs –if they are aware of them! Please,
these are not food likes and dislikes, but necessary adjustments for health purposes.
HEALTH FORM - All 4-H’ers have a Health Form on file in the 4-H Online System. However, you MUST go online at
https://florida.4honline.com/Login.aspx to verify your information is correct and update the verification date to May 29th or
after. Buddies must register in 4-H Online as short-term members.
FLORIDA 4-H MEDICATION FORM – The original Medication Form must be submitted at check-in with any and all
medications sent to camp. You must submit a copy of this form (no medications) with your Camp Packet. This form was
created to assist the camp nurse in properly administering your camper’s medications; it should be completed for all medicines sent
with the camper. All prescription medications must be in their original bottles with administration directions labeled. Please send
only enough medicine for the week. Bottles will be returned to the parent when the youth is picked up.
OVER
QUESTIONS AND ANSWERS ABOUT SUMMER CAMP
June 8-12, 2015
Campers’ Orientation ~ Tuesday May 19, 2015
Palmetto Fairgrounds, Rogers Auditorium ~ 7:00 p.m.
WHO
4-H members and buddies who are ages 8-12 as of September 1, 2014.
CIT Leadership participants, CIT, Counselors/Keys have been selected and notified of their role at
Junior Residential Camp.
REGISTRATION
Now through Monday, May 4 th at 5:00 p.m. Camper space is limited and will be available on a
first-come, first-served basis.
COST
Registration fee is $221 per camper; $110.50 per CIT Leadership Participant; $60.00 per CIT; and $30
per Counselor/Key and Volunteer Adult. (All fees are non-refundable after May 26, 2015.) This fee
includes meals, transportation to and from camp, camp tee shirt, arts and crafts supplies, instructional
supplies, refreshment breaks, and canteen.
CAMP
CHECK-IN
Monday, June 8, 2015
 8:00 - 9:00 a.m. - Rogers Auditorium, 4-H Center
1303 17th Street, West, Palmetto
 8:45 - 9:45 a.m. - Bethany Church
Corner of Verna-Bethany Road & SR 64 East, Myakka City
DEPARTURE
The Ag Center bus(s) will leave from Palmetto at 9:15 a.m. The Verna Bethany bus will leave Bethany
Church (corner of Verna-Bethany Road and SR 64 East) at 10:00 a.m. or as soon as the Ag Center bus
arrives. The buses will travel in tandem to 4-H Camp Cloverleaf in Lake Placid.
CIT Leadership participants will travel to camp with campers on Monday; Counselors/Keys and CIT will
depart from the Ag Center on Sunday, June 7, 2015 at 1:30 p.m.
MONDAY LUNCH
Lunch is our first meal at Camp Cloverleaf - DO NOT BRING DRINKS OR FOOD WITH YOU.
Snacks are provided at camp, do not bring them, they draw all kinds of “critters” into the cabins. “Care
Packages” of food from home will be donated to the 4-H State Residential Staff.
WHERE
4-H Camp Cloverleaf, is located on Lake Frances in Highlands County just outside of Lake Placid;
Campers are housed in air-conditioned cement-block cabins with bunk beds with bathroom facilities
close by. Counselors are housed in cabins with the campers. There are cabins available for youth with
handicapped conditions as well. Adults are housed in cabins by the lake.
CAMP RETURN
Campers will return to the Verna-Bethany site at approximately 2:30 p.m. on Friday, June 12th and the 4H Office at approximately 3:00 p.m. Departure time is dependent upon our noon meal and awards
program as well as the official release from Camp by the State Staff. When we get an ‘all clear’ from the
Camp Director we will board the buses for our return trip. We will call the County 4-H Office when we
depart so that families can plan when to arrive at the Friday drop-off sites. Parents please call the 4-H
Office (941.722.4524) to verify camp departure time. Arrival times listed are approximate.
WHAT TO BRING
You will be at camp for five days - Monday noon through Friday lunch. On the back of this page is a
"packing list" to help you. Please, be sure ALL items are marked with your camper’s name.
OVER
WHAT TO BRING
*Sheets & Blanket (for bunk bed) or Sleeping Bag
Pillow
Towels (2) (swimming & bath)
Flashlight
Wash Cloth
Soap
Shampoo
Deodorant
Shirts
Shorts (no higher than 4” above the knee)
Long Pants
Underwear
Shoes (Closed Toe & Heel) (2 pair)
Shower/water shoes for showers and swimming
Socks
Tooth Brush/Tooth Paste
Plastic Bags for Wet/Dirty Clothes
Bathing Suit (one piece or covered with a colored tee
shirt that falls below the waistline)
Clothes Pins
PJ’s (suitable for public display)
(Shower Shoes are strongly encouraged)
*Cabins get very cool at night Don’t forget a warm blanket
or a sleeping bag.
Please be sure to name/mark all your clothing, bedding and
towels. ‘Lost’ items will not be transported back to the 4-H
Office.
PROHIBITED
DO NOT BRING TO CAMP
If brought to camp, these items will be taken from
you and returned to your parents upon return
from camp. Serious infractions could result in the
youth being sent home. Remember the zero
tolerance cell phone and any electronic devices
policy applies.
This is an unplugged Camp~ this means: NO
Cell Phones, Pagers, Electronic Games, PDAs,
Laptop or Computers
Shaving Cream
Radios (Counselors will have
one)
Expensive Jewelry
Valuable Objects
Money
Gum, Candy, Food
Tobacco Products of any Kind
Alcoholic Beverages
Fireworks of any Kind
Water Pistols, Water Toys, or Balloons
Firearms or Knives
Apparel (i.e. t-shirts) with Obscene Language,
Culturally Insensitive Messages or Messages
Pertaining to Alcohol, Cigarettes or Violence.
Bikini Bathing Suits (boys and girls)
Camp is not the place for these things…
PLEASE LEAVE THEM HOME!
ABSOLUTELY NO BARE FEET AT CAMP
ABSOLUTELY NO OPEN-TOED OR OPEN-HEELED SHOES AT CAMP
(Please, leave them home also!)
SHOWER/WATER SHOES and FLIP-FLOPS ARE PERMITTED TO/FROM
WATERFRONT and THE BATHHOUSE.
CAMPERS MUST REMAIN ON THE SIDEWALKS
WATER-SHOES AND FLIP-FLOP AREAS WILL BE
MONITORED AND STRICTLY ENFORCED
OVER
ONLY REGISTERED CAMPERS/PARTICIPANTS, CHAPERONES, COUNTY STAFF, AND STATE
STAFF ARE PERMITTED ON THE GROUNDS DURING CAMP WEEK.
Night security includes bed/cabin checks at lights out; adult chaperones randomly patrolling grounds throughout the night.
FOOD IN CABINS
Campers and parents please do not bring/send food or beverages to camp. The cabins are places where
roaches and other critters love to visit and they WILL get into whatever is carried into the cabins. If the
camper needs snack items for medicinal purposes, they should be given to the camp nurse at camper check-in.
CANTEEN
Canteen is offered each day and is included as part of the registration fee. It is a chance for each camper to get
a beverage and one food item of their choice as a snack. Canteen is provided in addition to the two daytime
refreshment breaks.
PHONE
Please do not ask your child to call you upon arrival. Cell phones, tablets, laptop, PDA’s and pagers should
be left at home. If you have an emergency and need to reach your child, call Mrs. Angelita at 917.716.6003,
Camp Cloverleaf at 863.465.4884 or the 4-H Office at 941.722.4524. Phones at camp are not available to
campers; they are for business and emergency use ONLY. If no one answers your call, please leave a message.
Your call will be returned as soon as possible.
HEALTH/SAFETY
All youth will undergo a head lice check before boarding the bus for camp. If one fails the head lice test
(have head lice) he/she will not be permitted to attend camp. A refund may be issued.
A certified lifeguard will be on duty and present at all lake/waterfront activities. NO BARE FEET PLEASE.
Closed shoes (toe & heel) must be worn during all activities. Sidewalks and the bathhouse(s) are the
only areas where water-shoes or flip-flops are permitted. (Water-shoes and flip-flops are acceptable to
and from the waterfront area and in the showers only!)
BATH FACILITIES
MAIL AT CAMP
If you are sending prescription medicine to camp for your child, it must be brought in the prescription
bottle with your child's name on the medicine and enclosed in a zip lock bag. A Medication Form is
included with this packet and must be completed and enclosed with medications. All medications must be
turned in at camper check-in and will be housed with the Camp Nurse for dispensing. Please include written
instructions on how and when this medication is to be administered (original at check-in. A copy must be
submitted with your registration packet.) Medical emergencies will be handled at the Primary Care Unit in
Lake Placid. If your child is taken to the Primary Care Unit, you will be notified immediately.
Camper bathhouses are located directly behind the cabins; one on the girls’ side, one on the boys. The two
handicapped accessible cabins have bathroom facilities inside. The bathhouses have outside showers as well
as private shower and facility stalls. No showers should be taken between 10:00 p.m. and 6:00 a.m. when all
campers, counselors, and leadership participants are to be in their cabins.
If you wish to send your camper a letter remember, it takes approximately three days for a letter to arrive at
camp. Please, Please, Please do not send "care packages" of food or drinks. These items attract roaches
and rodents. Letters should be sent to:
CHILD'S NAME, MANATEE COUNTY
Cloverleaf 4-H Camp
126 Cloverleaf Road
Lake Placid, FL 33852
DISCIPLINE
Discipline should not be a problem at camp. Parents will be called to come immediately to pick-up their
child if a discipline problem does arise. A severe discipline problem could prevent a child from being
allowed to return to camp in the future. Knives, fireworks, firearms, cigarettes, chewing tobacco, snuff,
alcohol, shaving cream, cell phones or any other electronic devices; use of inappropriate language are
PROHIBITED. These items brought to camp and a language issue could result in the camper being sent
home.
2015 MANATEE COUNTY 4-H JUNIOR CAMP
REGISTRATION FORM
(Please PRINT all information CLEARLY. Packet should be returned in its entirety
Manatee County Junior Residential Camp
~ 4-H Camp Cloverleaf ~ June 8-12, 2015 ~ Cost $221 ~
NAME_____________________________________GENDER
(Last)
(First)
ADDRESS
HOME PHONE
CELL
ETHNIC__________COUNTY______________
M/F
CITY
ZIP_____________
AGE (as of 9/1/14) _____ DATE OF BIRTH ______________
ROOMMATE REQUEST
ARE YOU A 4-H CLUB MEMBER?
YES
NO
(Only one - must be same gender and age)
CLUB__________________________________
EMERGENCY CONTACT _______________________________ PHONE________________ RELATION________________
Adult XXL __ Adult XL
Please mark your tee shirt size here:
Adult L
Adult M
Adult S
Child L
Child M
Child S __
The following items must be included with your registration packet:
This completed Registration Form
Camp Financial Sheet (Your registration fee may include a scholarship amount.)
A Scholarship Nomination Form(s) must be submitted by your 4-H Club Leader and be in the 4-H Office by
registration due date (April 6, 2015).
**The Manatee County 4-H Fee Payment Policy applies to all summer program opportunities**
Camper Pick-Up/Drop-Off Points
Cell Phone, Graffiti, and Sickness Policies
Summer Food Meal Service Form
Special Dietary Needs Form
Medication Form - (attach a copy only.) Bring original form with medications to camp check-in.)
Health Form- updated as of 5/26/15 or later, online at https://florida.4honline.com/Login.aspx
Camps are age specific. Please be sure you meet the age requirement before you apply.
All Camp Registrations are due to the
Manatee County 4-H Office by 5:00 p.m., Monday, May 4, 2015
Mail registration packet & check payable to: Manatee County 4-H Foundation
1303 17th Street West Palmetto FL 34221
For more information call: 941.722.4524
**Manatee County 4-H Fee Payment Policy: If you sign up to attend an event that involves partial payment of fees by the Manatee County 4-H Foundation
or the Manatee County 4-H Leader Council and you are unable to attend, YOU will be charged for the amount of the fee that was paid by the Foundation or
Council if it is not possible to get a refund of fees.
If you do not make payment of this billing, you will be unable to participate in future programs requiring fee payments unless you make payment in full.
Reimbursement will be made by the Foundation/Council following successful participation in the program.
COUNSELOR/KEY/ADULT VOLUNTEER FINANCIAL SHEET
2015 Manatee County 4-H Camp
Camp Cloverleaf
Counselor/Key/Adult Volunteer’s Name_____________________________________
4-H Club Name________________________________________________________
Please use the chart below to calculate your fee:
Amount
COSTS
$ 30.00
(A) BASIC COST OF CAMP (includes Tee Shirt and Canteen Fee)
DEDUCTIONS
N/A
(B) DEDUCT $88.40 if you have a county awarded scholarship*
Don’t forget to write a thank you letter.*Manatee County 4-H Fee Payment Policy applies
(C) DEDUCT the amount $_____________of a club awarded scholarship.
Don’t forget to write a thank you letter.
You MUST
complete this
form if you
qualify.
(D) DEDUCT ($36.25) if you qualify for USDA Summer Food Meal Benefit Program.
Must Provide Case Number.
Every youth MUST return this form, if you do not qualify write “declined” across
each page of the form. Please return with your application.
(E) TOTAL DEDUCTIONS (B+C+D)
(F) GRAND TOTAL=Amount (A) minus total deductions (E).
This amount is due to the Manatee County 4-H Office by 5:00 p.m.,
Monday May 4, 2015 for your summer camp fees.
Make Check payable to:
Manatee County 4-H Foundation
For Office Use Only:
Tender___________ Amount___________ Date Received ____________
Receipt No._______________
*MANATEE COUNTY 4-H FEE PAYMENT POLICY
Effective April 1, 1997
If you sign up to attend a workshop, conference, camp, etc. that involves partial payment of fees by the Manatee County
4-H Foundation or the Manatee County 4-H Leader Council and you are unable to attend, YOU will be charged for the amount of the fee
that was paid by the Foundation or Council if it is not possible to get a refund on fees. If you do not make payment of this billing, you
will be unable to participate in future programs requiring fee payment unless you make payment in full and are reimbursed by the
Foundation or Council following successful participation in the program.
CIT/Counselor/Key/Volunteer Name_________________________________
CIT/COUNSELOR/VOLUNTEER PICK-UP AND DROP-OFF POINTS
Check the boxes below, indicating where you will be dropped-off following camp. Luggage on the return trip will be
loaded accordingly. Be sure to let your camper know where he/she is to get off the bus on the return from camp.
All CITs and counselors will
be leaving from the 4-H
Center on Sunday, June 7th
at 1:30 p.m. Please mark
where you will be droppedoff on Friday, June 12th.
LOCATION
DROP-OFF
FROM CAMP
Time**
DROP-OFF
Fri., June 12th
(√) Check one
4-H/Ag Center, Palmetto
3:00 p.m.
Verna-Bethany Rd @ Highway 64 East
(Bethany Church Parking Lot)
2:30 p.m.
Volunteers, please indicate the following:
When will you be traveling to camp? ____ Sunday ____ Monday
How will you travel to camp? ____ Riding Bus ____Own Transportation
If riding the bus on Monday, where will you be picked-up? ____ Ag Center ____ Verna Bethany
If riding the bus on Friday, where will you be dropped-off? ____ Ag Center ____ Verna Bethany
**Departure time is dependent upon our noon meal and awards program as well as the official release from
Camp by the State Staff. As soon as we get an ‘all clear’ from the Camp Director we will board the buses for
our return trip. We will call the Manatee County 4-H Office when we depart so that families can plan when to
arrive at the Friday drop-off sites; it takes about 1½ to 2 hours to travel from 4-H Camp Cloverleaf in Lake
Placid. The above listed Drop-Off times are approximates; please call the 4-H Office to confirm the
estimated times of arrival.
Youth’s Name ______________________
POLICIES RELATED TO MANATEE COUNTY JUNIOR CAMP
Camp is a unique environment where youth are encouraged to develop essential and lasting life skills. Please
stress to your child that when he/she signs a document, that signature is as good as their word. We respect
and appreciate the relationship youth and families may have, but if your child is to enjoy the experience fully
he/she must be able to develop a sense of independence and self-reliance. If there is an emergency or a
concern about your child’s well-being, he/she will be allowed and encouraged to call home.
ZERO TOLERANCE CELL PHONE POLICY
Youth participants are not allowed to bring (working or non-working) cell phones or any other electronic
devices to camp. If a cell phone and/or other electronic device is brought to camp the parent will be called
and the youth will go home.
I, _____________________________, understand and agree not to bring a cell phone or any other
(Signature of Youth)
electronic devices to camp.
GRAFFITI/PROPERTY DAMAGE POLICY
Graffiti is defined as words or images that are written, scratched, painted or sprayed on walls/surfaces.
Campers should do not deface or vandalize ANY camp property. Campers/county will be held responsible
for any and all graffiti/damages and will be subject to any costs associated with the cleanup/repair of said
graffiti/damage.
I, ____________________________, understand that I am not to deface or vandalize any camp property.
(Signature of Youth)
SICKNESS POLICY
If your child becomes ill during their stay at camp, our policy will be the same as the Manatee County
School Board. Limited space is available in our nurse’s area; therefore every effort will be made to contact
you if your child is sent to the nurse and determined to be too sick to remain at camp. You will be asked to
pick up your child if he/she is vomiting or running a fever.
In case of an emergency, you may contact: 4-H Camp Cloverleaf at 863.465.4884 or the Manatee County
4-H Office at 941.722.4524. Further contact information will be made available to you.
I, ____________________________,
(Print Name of Parent/Guardian)
have read the Zero Tolerance Cell Phone, Graffiti/Property
Damage, and Sickness policies. I understand and agree to these
policies and have also explained these policies to my
child and they agree to compliance.
_____________________________________
(Signature of Parent/Guardian)
____________________________
(Date)
SPECIAL DIETARY NEEDS FORM
INSTRUCTIONS: The purpose of this form is to communicate special dietary needs, food
allergies, etc. for any child, teen, or adult who will be attending 4-H camp.
Name:________________________________ County: Manatee
Please Check One of the Following:


Camper (8-12 years old)
Adult Volunteer or
Extension Faculty/Staff

CIT Leadership

CIT/Counselor/Key
In the space below, please list all food allergies for the person listed above and any
necessary precautions that should be taken:
In the space below, indicate food restrictions (non-allergy) for the person listed
above and food substitutes that may be considered:
Florida 4-H Medication Form
To help us become more efficient, we are requesting that you complete this form, then submit a copy with your camp
registration packet. The original (with changes, if any) will be brought in with the medication on the day you leave for
camp. Thank you very much for your assistance.
Youth Name: _______________________________________________
4-H County: Manatee
Directions for Parents and Guardians: Please complete this form for any medication your child will be taking
while attending any 4-H activity, including non-prescription drugs, lotions, inhalers or any other items. This form
must accompany your child’s medication for the activity. Any medication not meeting the following requirements
will not be allowed at a Florida 4-H activity.
All prescription medications MUST:
 Be in the original container with a prescription label
 Be properly labeled with the youth’s name, dosage, & frequency
 Have directions that match what is prescribed
 Have the doctor’s name and prescription number
 Not be expired
 Sample medications must have a written prescription from doctor
Special consideration for inhalers and/or Epinephrine (“EpiPen”):
 The inhalers and/or EpiPens should be in their prescription box with their prescription label.
 If you’ve thrown out the box, your pharmacy can print you a label to bring, but it must match the
medication and still be in date.
 We cannot accept expired inhalers or EpiPens.
All over the counter medications (includes ear drops/swim ear, allergy meds, pain relievers, vitamins etc.) MUST:
 Be in the original container
 Marked with youth’s name
 Not be expired
I request that a person designated by Florida 4-H give my child, _____________________ the following
medication:
1) Name of medication: __________________________________________________
Amount to be given: _____________________________________________________
Time of day to be given: __________________________________________________
Directions, if to be given “as needed”: ______________________________________
Dates medication is to be given: From ____/____/____ To ____/____/____
Prescribing doctor’s name: _______________________________________________
Illness or condition prescribed for: ________________________________________
If inhaler or EpiPen, does the youth have to carry on-person and self-medicate?
Yes ____ or No____
I agree to furnish Florida 4-H with the medication(s) listed on this form per the guidelines above. I further
understand that Florida 4-H’s designated person will administer the medicine to my child in good faith, at request. I
certify that I have signed the Florida 4-H Medication Consent provision in addition to this form.
______________________________________
Parent/Guardian Name (Please Print)
__________________________________
Parent/Guardian Signature
_______________
Date
If you are sending more than one medication for your child, please complete the second page of this form.
Florida 4-H Medication Form
Page 1 of 2
Revised August 14, 2014
Florida 4-H Medication Form
Youth Name: ___________________________________________
4-H County: Manatee
Additional Medications
2) Name of medication: __________________________________________________
Amount to be given: _____________________________________________________
Time of day to be given: __________________________________________________
Directions, if to be given “as needed”: ______________________________________
Dates medication is to be given: From ____/____/____ To ____/____/____
Prescribing doctor’s name: _______________________________________________
Illness or condition prescribed for: ________________________________________
If inhaler or EpiPen, does the youth have to carry on-person and self-medicate?
Yes ____ or No____
3) Name of medication: __________________________________________________
Amount to be given: _____________________________________________________
Time of day to be given: __________________________________________________
Directions, if to be given “as needed”: ______________________________________
Dates medication is to be given: From ____/____/____ To ____/____/____
Prescribing doctor’s name: _______________________________________________
Illness or condition prescribed for: ________________________________________
If inhaler or EpiPen, does the youth have to carry on-person and self-medicate?
Yes ____ or No____
4) Name of medication: __________________________________________________
Amount to be given: _____________________________________________________
Time of day to be given: __________________________________________________
Directions, if to be given “as needed”: ______________________________________
Dates medication is to be given: From ____/____/____ To ____/____/____
Prescribing doctor’s name: _______________________________________________
Illness or condition prescribed for: ________________________________________
If inhaler or EpiPen, does the youth have to carry on-person and self-medicate?
Yes ____ or No____
Florida 4-H Medication Form
Page 2 of 2
Revised August 14, 2014