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CAMPER APPLICATION
2015 Pima County 4-H Horse Camp
June 21-27th, 2015
Santa Cruz County Fairgrounds
Sonoita, AZ
More info: http://www.pimacountyhorsecamp.com
Pima County will once again host a 4-H Horse Camp. Come to Horse Camp to train and play in a particular discipline
of horsemanship. Campers receive 4-5 hours of daily instruction with amateur and professional horse trainers.
Afternoons and evenings are filled with guest speakers, crafts, games, and other fun activities.
CLASSES OFFERED:
Western Performance/Trail Gymkhana** Ranch Sorting Fundamental Roping
All classes are subject to minimum and maximum enrollment. Classes may be canceled, combined, or split depending
on the number of enrolled/interested campers. Campers may be moved to their next choice of discipline at the
discretion of the staff. We reserve the right to cancel a discipline offered due to lack of interest. (low to no camper’s
choosing of said discipline as their 1st choice)
**Gymkhana campers must be able to catch both leads on their horse to enroll in this discipline.
FEES:
Registration is $310.00. This Registration fee includes instruction, meals for campers, sleeping facilities, arts and crafts supplies,
camper t-shirt, and horse stall. All campers are charged a $10.00 refundable stall deposit. (Will be returned at checkout if horse
stall left clean.) In addition, all Ranch Sorters and Ropers will be charged a $40.00 cattle fee. If you apply before March 30, 2015
your registration will be discounted $25… If you send this form after May 1st, there will be a late fee of $50. All fees are nonrefundable after May 20th, 2015, unless explicitly noted as in the stall deposit. Cancellations due to family emergencies, in regards
to refunds, will be handled on an individual basis. If camp is cancelled by Pima County 4H Horse Project for any reason, all, fees
will be refunded. If you are planning to pay by credit card, there will be an additional $10.00 charged per camper for this
option. If paying by check please send with registration.
Fee Example: The cost for Gymkhana, Western, and English is $320.00 The cost for Sorting and Roping is $360.00 . Plus: $10.00 per camper credit card fee.
These fees, Do Not include shavings, which are required for your horse’s comfort, so please bring shavings with you to camp. We will post to web site, and/or
Facebook page, if shavings will be available for purchase on check-in day from local Sonoita Feed Stores. Fees also do not include feed so bring enough to feed your
horse for entire week.
TO APPLY: (please read carefully as the application process has changed this year.)
Complete, sign and send all registration documents: Application, Risk Assumption, Medical Release, and Photo
Release. If paying by personal check please send payment with registration. It is no longer necessary to send Money
Orders or Cashier’s Checks, however, this form of payment is still acceptable. If paying with credit card, send in all
registration documents and invoice will be sent to you via email with Instructions for paying with credit card, and any
invoice that is not paid in full within 10 days of being sent will be voided. This means that the camper’s registration
will also be cancelled and the space reserved in that discipline will be made available to other campers. We expect
more camper’s this year so please mail early to secure your space in the discipline of your choice.
Please fill out this form carefully and choose your ranking of disciplines thoughtfully as they cannot be changed without $50.00 change fee. (There is a great deal of
cost to make changes after-the-fact.) There will be absolutely no changes after May 20th , 2015.
Mail Application to:
Pima County 4-H Horse Camp
c/o Desert View Lath and Plaster, Inc.
2433 W Placita Desierto Morado
Tucson, AZ 85705
Keep this page for your reference
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Registration is limited to 100 campers. All disciplines will be assigned on a first-come basis. All mail is date stamped. Registration
deadline is May 1st, 2015. Send in your application early so that you have the best chance at your first choice of disciplines. Late
Registration will be available for an additional $50.00 fee. Late registration is limited to space in disciplines so please call for
availability.
SCHOLARSHIPS: There are a limited number of Partial ($100) scholarships available for camp. Those applications will be
published on same site as this application. These Scholarships will be awarded as a reimbursement at checkout from camp.
THIS WILL BE A CLOSED CAMP. No visitors/guardians/parents/grandparents/siblings etc… will be allowed at anytime
after youth and horse have been dropped off, until checkout time.
If you have further questions after reading these materials, call Kelly Cook: 520-907-0431, or Sammy, Kelsey, and Kelly’s email [email protected]
The University of Arizona College of Agriculture is an equal opportunity employer authorized to provide research, educational information and service only to
individuals and institutions that function without regard to sex, race, religion, color, national origin, age, Vietnam Era Veteran’s status, or disability.
Check In: Sunday, June 21nd, 2015
NOT Before - 2:00 PM.
Orientation: Dinner, Sunday, June 21nd at 6:00 PM, (Parents and siblings are welcome to join us for dinner,
$5.00/person)**
Daily Schedule EXAMPLE
6:00 - 6:30 AM
Wake up, dress
4:30 - 5:30 PM
Feed, Water, Clean stalls
Feed and water horses
5:30 - 6:30 PM
Dinner/Dining hall duty
6:30 - 7:30 AM
7:30 – 12:30 PM
Breakfast
Train with horse
6:30 - 8:30 PM
7:00 - 10:00 PM
Evening event
Friday: Dance
12:30-1:00 PM
1:00 - 2:00 PM
2:00 - 4:30 PM
Clean up for lunch
Lunch/Lunch duty
Group Activity
8:30 PM
9:30 PM
10:00 PM
Showers/Snacks/Movies
Quiet Time /Meditation
Lights out!!!!!
Check In: Will not begin before 2:00pm on Sunday, June 21nd, 2015 (Everyone must be in their places)
Check out: Saturday, June 27th, 2015, after 9:00 AM. All campers must be picked up by 11:00 AM. If any camper is left
after this time, there will be a childcare charge of $10.00 per ½ hour.
Be prepared to clean the stall at the end of camp if you wish the return of stall deposit.
Parents please remember to bring cash when picking up your camper/horse from camp. Medical, feed,
veterinary, and farrier charges must be paid for at that time. We will contact you before we purchase anything on your behalf.
A required list of things to bring to camp,. as well as a few things that will make life a little easier but are not
necessary, will be sent with welcome letters as well as being available on the web site. Our Facebook page is also a great
place
to
get
information and
for
campers
to
check
out
pictures
from previous camps.
https://www.facebook.com/friends/requests/?fcref=rup#!/PimaCounty4HHorseCamp
If you would like to be alerted when changes and/or updates made to Facebook or Web Site please
like our Facebook Page.
The temperature in June in Sonoita varies greatly from day to night, and there is always the possibility of rain
showers, so please bring appropriate clothing and shoes.
NO FOOD MAY BE BOUGHT INTO CAMP
THERE WILL BE A SNACK BAR FOR CAMPER’S TO PURCHASE SPECIAL TREATS
IF YOU HAVE SPECIAL DIETARY, NEEDS PLEASE CONTACT STAFF AT: [email protected] IF YOUR
CHILD REQUIRES THAT WE PURCHASE AND PREPARE SPECIAL FOOD THERE WILL BE AN ADDITIONAL
CHARGE. (A VARIETY OF FRESH FRUIT AND VEGETABLES ARE SERVED WITH EVERY MEAL)
Keep this page for your reference
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Rules of Conduct
All campers will be required to conduct themselves as young Ladies and Gentleman and follow General 4-H
rules. Politeness, respect, and good sportsmanship are mandatory - No Exceptions. Failure to comply may
result in the camper being sent home and additional 4-H participation may be restricted. There will be no
refunds if camper sent home early.
General Camp Rules:
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Use/possession of weapons of any type, lighters, alcohol, tobacco, or illegal substance is prohibited.
No girls in the boy’s dorm area, no boys in the girl’s dorm area.
No visitation after lights out. No flashlights on after lights out.
Respect your fellow camper, no fighting.
Use appropriate language. No profane language or gestures.
Respect the camp. Do not harm the plants, animals, or camp property. No littering.
No fires allowed.
Camp is for you. Participation is required in all programs and duties.
All medications, (prescription and non-prescription) must be turned in to the camp medical personal
upon arrival.
Camp counselors and adult staff are there to help you. Follow their instructions.
Water fights are to be held in designated areas only. Non-compliance will result in disciplinary action.
Roping in designated areas only.
Barn Rules:
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All problems in the barn area are to be reported to the barn manager or other staff immediately.
No people horse- play in the barn area or around tied horses.
No swinging ropes around horses.
No bell or splint boots left on stalled horses. Shipping boots, leg wraps are OK, if properly applied.
Water containers for the horses shall be large enough to supply water to the horse for 12 hours.
The containers will be kept clean.
Feed containers shall hold enough feed for a single feeding. Hay nets will be tied high. No feeding on
bedding.
Bedding is required. Stalls will be cleaned as scheduled.
No locks on stall doors. Snaps are encouraged to secure all gates.
Tack shall be kept in the tack stall and properly stored. A halter may be hung outside the stall.
Horses are not to be tied in alleys, except for cleaning stalls, saddling, and unsaddling.
Campers shall keep the alleys clean.
No campers in the stall area after curfew.
All 4-H safety rules apply. No bareback riding. Walk only outside of the arenas.
Reminder - All campers and counselors must wear an approved equestrian helmet.
For the safety of your horse and others, please make sure your horse is properly vaccinated.
Keep this page for your reference
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REGISTRATION FORM
2015 Pima County 4-H Horse Camp
June 21st to June 27th, 2015
Santa Cruz County Fairgrounds, Sonoita AZ
For ages 9-19 as of January 1, 2015
Date Stamp: ___________________
(received)
Date Invoiced: ___________________
Payment recorded: ________________
Proofed by: ____________________
Notes: ____________________________
Early Bird: _______________________
Referral: _________________________
NAME:________________________________________________PHONE:__________________________ _
ADDRESS:______________________________________________CLUB:___________________________
CITY:_________________________________________MALE:_________________FEMALE:__________ _
STATE:_____________ZIP:______________AGE:________BIRTHDATE:___________________________
Email address: ________________________________________________(for payment request)
Horse has stalling problem: ______________________________________________________________
How many years have you attended Horse Camp?________ Count this year as year one if your first time.
What size adult T-Shirt do you wear? small___ medium ___ large___ 1x___ 2x___ 3x___
Enrollment for Instruction
You will be working in one of the areas of interest (discipline) for the ENTIRE CAMP. NO CHANGES IN
CLASSES WILL BE MADE. The staff reserves the right to place the camper at another level if necessary. Your
horse must be a safe horse for you and must be appropriate for your level of instruction. Don’t bring a parent’s horse
just because it is available if it doesn’t fit your skill level. No Green horses. No new horses. Must be able to catch
both leads to participate in Gymkhana discipline. This is not the camp for Walk-Trotters. All campers must be at the
beginner riding level to attend camp.
Number your choice in order of preference
(1,2,3,4) 1 being most desired
Indicate your level of performance
Beginner, Intermediate, Advanced
______Western Performance/Trail
______Gymkhana
______Team Sorting
______Fundamental Roping
______English
Level___________________
Level___________________
Level___________________
Level___________________
Level______________ (Due to past years #’s class may be cancelled)
I, ________________________________ give permission for ___________________________________to participate in the
2015 Pima County 4-H Horse Camp and bring one horse only (no green horses, no mares with foals and no stallions). If the
manageability of the horse creates a safety issue for the other campers, the rider or the horse itself, a call will be made and I agree
that the camper and horse will be picked up if there is no replacement horse available. The horse need not be a 4-H registered
horse during the 2015/2016 4-H year, but must be healthy, sound and of appropriate disposition. A licensed veterinarian will be on
call for veterinary care if required. A farrier will come to replace shoes if necessary. Any expenses incurred by my son or
daughter’s horse will become my responsibility. Feed will not be available at camp. My Camper will bring enough feed for his/her
horse for the entire camp period.
I certify that ____________________________is (is not) a 4-H member in good standing for the 2015/2016 4-H
year and is physically able to in the activities of the 4-H camp. (Need not be 4-H member to attend 4-H horse camp.)
* Parent/Guardian Signature _________________________________ Date ____________________
Acknowledgement of Rules
I have read the Rules of Conduct; General Camp Rules and Barn Rules. I agree to obey all rules at the 4-H Horse Camp.
* Campers Signature _______________________________________________
Date __________
I have read the Rules of Conduct; General Camp Rules and Barn Rules. I understand that if my child does not obey the rules, I
will be called to pick him/her up immediately, and /or that it may result in additional 4-H participation restrictions.
* Parent/Guardian Signature ________________________________________
Date ____________
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Medical Release/Emergency Information
The following medical information about this 4-H member is for the purpose of obtaining immediate medical attention
if necessary and institute adequate precautions and/or programs to make Horse Camp a safe and enjoyable experience.
NAME:_______________________________________________BIRTH DATE:____________________
ADDRESS:________________________________________________________________________
CITY:_____________________________________STATE:______________________ZIP:__________
PARENT/LEGAL GUARDIAN NAME:____________________________________________________
HOME PHONE:________________WORK PHONE:________________OTHER:___________________
Are there limitations on who may see/pick up your child? _______________________________________
What other adult may be called in an emergency?_____________________________________________
Phone numbers:_______________________________________________________________________
Family Physician:___________________________________________Phone:_____________________
Facility of Choice (if an emergency)_____________________________________________________
Insurance Company:_______________________________________ Policy number:________________
Allergies: Medications:____________________________________________________________
Foods:_________________________________________________________________
Date of last Tetanus shot?_______________________ Immunizations current?____________________
Medications are to be given to Camp First Aid Staff, on registration day June 21st, 2015. I also understand that my
child’s medications will be kept in a locked container and dispensed with your permission by First Aid Staff. I give
my consent for my child to receive the medication below and have initialed the drugs below that can be given when
conditions warrant the need i.e. headache, allergic reaction, up set stomach, itchy rash etc….
(guardian’s initials, required next to medicines First Aid Office may dispense)
Tylenol \ Acetaminophen _______ Ibuprophen ________ Benadryl________ Pepto Bismol ________
Hydrocortisone cream 1% ________
Medications taken (include name, dose, frequency). Must be in original container only.
________________________________________________________________________________________
_______________________________________________________________________________________
Does your child have any special needs?
Dietary?______________________________________________________________________
Physically?____________________________________________________________________
Emotionally?___________________________________________________________________
Please check any that apply: Hypoglycemia___ Diabetes___ Ulcers___ Headaches___ Asthma___
Nose Bleeds___ Anemia___ Visual Problems___ Hearing Problems___ Bleeding Problems___
Previous Fractures? Where_____________________________________________________________
Any Types of activity prohibited due to physical limitations:___________________________________
Joint Problems? Yes / No: Knee____ Hip____ Back/Neck____ Ankle____Wrist___ Elbow___ Shoulder___
Explain any Yes answers below:
_______________________________________________________________________________________
_______________________________________________________________________________________
*** In the event of a medical emergency, I hereby authorize the named representative(s) to employ a
licensed medical doctor to render any medical services, which may, in the sole direction of the doctor, be necessary.
I further authorize said representative(s) to take the child to the hospital if it should be deemed necessary and I agree
that I will pay all doctor and hospital bills. I agree to indemnify and hold harmless all organizations and entities
associated with Pima County 4-H Horse Camp including all officers, employees, agents, and others from loss and
claims involved with my child’s participation in the 4-H Horse Camp. By allowing my child to participate in the 4H Horse Camp, the associated organizations and entities assume no responsibility for injury or damages incurred by
my child. I further understand that I shall bear full responsibility for the consequences of my child’s own actions.
My signature attests that I have read, understand and agree to the terms of this document.
* Signature of Parent/Guardian _____________________________________
Date ____________
Page 6 of 8
2015 Pima County 4-H Horse Camp
June 21-27th, 2015
Santa Cruz County Fairgrounds
Sonoita, AZ
PHOTO RELEASE FORM
I grant permission to The Arizona Board of Regents, on behalf of the University of Arizona and
its agents, employees and volunteers, to use photographs taken of me on the date and at the location
listed below for use in university publications such as recruiting brochures, newsletters, and magazines,
and to use the photographs on display boards, and to use such photographs in electronic versions of the
same publications of on University web sites or other electronic for a or media, and to offer them for
use or distribution in other non-university publications, electronic or other wise, with out notifying me.
I hereby waive any right to inspect or approve the finished photographs of printed or electronic
matter that may be used in conjunction with them now or in the future, whether that use is known to me
or unknown, and I waive any right to royalties or other compensation arising from or related to the use
of the photograph.
I here by agree to release, defend, and hold harmless the Arizona Board of Regents, on behalf of
The University of Arizona and its agents, employees, or volunteers including any firm publishing
and/or distributing the finished product in whole or in part, whether on paper or via electronic media,
from and against any claims, damages or liability arising from or related to the use of the photographs,
including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in
composite form, either intentionally or otherwise, that may occur or be produced in taking, processing,
reduction or production of the finished product, its publication or distribution.
I am 18 years of age or older and I am competent to contract in my own name or I am parent or
guardian of child named below. I have read this release before signing below, and I fully understand the
contents, meaning and impact of this release. I understand that I am free to adders any specific
questions regarding this release by submitting those questions in writing prior to signing, and I agree
that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this
release.
Location of Photo: Santa Cruz County Fair Grounds / Horse Camp 2015- 6/21/15 through 6/27/15
Name of Camper (please print)_______________________________________________
* Campers Signature ________________________________________
Date ___________
* Signature of Parent/Guardian _________________________________
Date ___________
Page 7 of 8
University of Arizona
Pima County 4-H Youth Development Program
Pima County Horse Camp
4-H Horse Project
Assumption of risk statement for the ANIMAL
I,___________________________________, desiring to participate in Pima County 4-H Horse Camp, do so at my
own risk, realizing that participation in these activities, including showing my animal, in general can increase the risk
of injury to my animal and these activities in particular have their own unique risk factors. I agree to follow all rules
for participation. By permitting me to participate in these activities, the University of Arizona and Pima County Horse
Camp, including their officers, directors, servants, agents and/or employees, assume no responsibility for injuries or
damages incurred by animal during my participation in the project or in the planned educational activities associated
with this Horse Camp. I understand and voluntarily assume those risks and will not hold these groups responsible for
injuries resulting from any inherent risks. I further understand that I shall be full responsibility for the consequences
of my own actions.
Failure to follow any rules stated in the Pima County 4-H rules, and Horse Camp Code of Conduct may
result in suspension or expulsion from further Horse Camp activities.
_______________________________________
Signature of Member
________________________________________________
Signature of Parent or Guardian
_________
Age
____________________
Date
_____________________________
Date
INDIVIDUAL ASSUMPTION OF RISK STATEMENT
I, ______________________________________________ desiring to participate in 4-H Horse Camp at the Pima
County 4-H Horse Camp in Sonoita, AZ in 2015, do so at my own risk, realizing that participation in general can
increase the risk of injury and that horse events in particular have their own unique risk factors.
By permitting me to participate in these activities, the University of Arizona, and the Pima County 4-H Horse,
including their officers, coordinators, staff, servants, agents, and/or employees, assume no responsibility for injuries
or damages incurred by me during my participation at the camp or in the planned educational activities associated
with this camp. I Understand and voluntarily assume those risks and will not hold these groups responsible for
injuries resulting from any inherent risks. I further understand that I shall bear full responsibility for the consequences
of my own actions.
_______________________________________
Signature of Member
_________________________________________
Signature of Parent or Guardian
___________
Age
_____________________
Date
______________________
Date
Page 8 of 8
MAIL ALL FORMS TO:
Pima County 4-H Horse Camp
c/o Desert View Lath and Plaster, Inc.
2433 W Placita Desierto Morado
Tucson, AZ 85705
Certified or Registered Mail is accepted but does not get any different treatment than those received regular
post that is received same day. Welcome letters with packing lists will be sent via email by 5/30/15
YOU WILL RECEIVE: Invoice via email that will serve as
confirmation of reservation for horse camp. Invoices will be issued and emailed
on the Saturday of week registration received. Your discipline placement will be on the invoice. Register early
to guarantee placement in your first choice of discipline.
Credit Card PAYMENTS: Must be received within 10 days of
invoicing to secure Camper’s place in discipline of their choice.
First invoicing not to occur before March 20, 2015
Check List of Documents that must be included in your application:
1) Application Form
2) Medical Form
3) Risk Assumption Document
4) Photo Release Form
Welcome Letters will be sent the first week in June 2015. If there is an additional email address you would
like me to send welcome information please add it below. If any check returned for NSF the camper’s space
in discipline will be voided and a reinstatement fee of $50.00 will need to be included in Cashier’s Check
amount to reinstate camper.) No personal checks will be accepted after May 1st, 2015. Please do not abuse the
new system of accepting personal checks by sending payment that may be returned for Non-Sufficient-Funds.
Email:__________________________________________________
Email:__________________________________________________
________ $310.00 Registration
________ $ 40.00 Cattle Fee
________ $ 10.00 Stall Fee
________ $ 10.00 Credit Card Fee (per camper)
________ $ 50.00 Late Fee
-_______ $ 25.00 Early Registration Discount
________ $ 50.00 Change Fee
________ $ ________ Donation to Horse Camp (Scholarship)
________ $ 5.00 x __________(person(s)) staying for dinner Sunday evening (Spaghetti)
_____________ Total Payment (Charge)
SEE YOU ALL AT CAMP!!!!!!!!!!!!!!!