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Date Stamp: ____________________________
(Received)
Referral: _______________________________
Pima County 4-H Horse Camp 2015
Counselor Application
June 21 – June 27, 2015
There will be a mandatory Counselor Meeting on May 30st, 2015 at 11:00am, lunch will be provided. (The
meeting will be at 6775 W El Camino Del Cerro, Tucson. Directions will be provided in a later mailing.) Please
read Counselor Code before filling out application. Must be at least 15 years old to apply.
Plan on at least 2-3 hours. If you cannot attend this meeting, stop right here, no need to fill out this form. This is a
job, not a vacation for counselors. You will be in charge of 4 to 6 campers for 6 days 24 hours a day. This is a
community service you are volunteering for, and you will receive a certificate stating the community service hours
you completed at Horse Camp. You will be required to come a day early and stay a day later than the camper’s to
clean-up and prepare for their arrival and departure. If you do not want to work hard to have the privilege of being
counselor and being a positive role model for these young equestrians, please do not fill out this form. There is time
for socializing and having fun before and after camp, but this is a serious job you are undertaking being a counselor
at Horse Camp. (There is no charge to be counselor at this camp as in other 4-H camps and you will still be attending
daily training sessions with camper’s either on or off your horses at Trainer’s discretion.)
Name: ______________________________________________________(PLEASE PRINT CLEARLY)
Address: _____________________________________________________City: _______________
State: ______ Zip:___________ Email Address: ________________________________________
Home Phone: _______________ Other Phone: _____________ Birth date: ___________ 18?___
4-H Club: _____________________________ 4-H Club Leader ________________________
What size adult T-Shirt do you wear? Small___ Medium ___ Large___ 1x___ 2x___ 3x___ Years in 4-H
_______ Years in Horse Project: ________ Male: ____ Female: ____
Previous Counselor? Yes ___ No ___ Will you be bringing a horse to camp? Yes ___ No ___
Horse has stalling problem:___________________________________________________________
What discipline (if you had a choice) would you want to be a counselor in? Number your choices 1 being first
choice. Western ____ Gymkhana ____ Sorting ____ Roping ____ English___Remember there is no guarantee
you will be in discipline of your 1st choice)
Please Mail all applications to:
Kelly Cook – Horse Camp c/o Desert View Lath and Plaster, Inc.
2433 W Placita Desierto Morado
Tucson, AZ 85705
Use additional paper or back for more space in answering these questions. Please Be honest. Print Clearly.
1. What special skills, talents, and abilities do you have that are applicable to being a camp counselor?
2. Why do you want to be a counselor?
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3. Please list and briefly tell us of any previous counselor experience.
4. Please tell us about your leadership abilities and provide examples that demonstrate them.
5. Please tell us about your hobbies and interests.
6. Describe what you think counselor’s responsibilities are.
7. Please tell us about your skill set and knowledge level of horses, tack etc….
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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(s):_____________________________________________________________
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 number:________________
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 Medical Personal on registration day June 24, 2015. I also understand that my child’s medications
will be kept in a locked container and dispensed by the camps medical personnel. 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….
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 the 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
4-H 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 ____________
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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 hereby 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 6/20/2015 through 6/28/2015
Name of Counselor (please print)_______________________________________________
* Counselors Signature ______________________________________________ Date ___________
* Signature of Parent/Guardian _______________________________________ Date ___________
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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 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
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Counselor Code
Please bring your questions with you for the Counselor Meeting on May 30th 2015.
I expect everyone (Counselor’s and Staff) there by 9:00am on Saturday Morning, June 20th,
2015 ready to clean. (That means horse must be put away, if you bring one, before start time,
we have much to do to get property ready for campers.) You will be at camp until Sunday June
28th when property is cleaned after campers leave. If we are done early on Saturday you may
leave when we are done. This means that we leave the property better then we received it.
(We have been done around 4:30pm on Saturday after camper pick-up the last couple years, but not guarantee that it will be same
this year.)
Check List
Any personal hygiene items that you will need for showering, deodorizing, and oral care. Your campers will be
looking up to you. They will want to be like you. Teach by example, be a good role model.
Hat or Visor
Sun Screen
Warm jacket and rain gear, the nights can be cold and the afternoons rainy.
Boots or approved riding shoes for horse riding.
Bathing suits for showering.
Sleeping bag or bedding, cot, and pillow.
Appropriate spending money.
If you are bringing a horse, you will need: Halter and leads, helmet, appropriate tack for the discipline you are in,
feed, hose, and 20 gallons minimum water container, wheelbarrow and apple picker.
Smiles and Big Hearts
Dress Code
No bellies showing
One inch straps on all tank tops with no undergarments showing. (Two finger rule is best judge of strap width)
Shorts must be of appropriate length (10” from the knee when kneeling)
No sagging pants of any type.
No inappropriate holes in clothing.
No alcohol, tobacco, sex, or profanity on clothing
No halter tops, tube tops, or spaghetti strap tops.
Appropriate sleeping wear
Appropriate shoes for showering, riding and other activities
Lip Balm and sunscreen
If you dress inappropriate, you will be given something to change into. (This will be determined by staff)
FYI
No food will be allowed to be brought into camp. We will have a great snack bar for afternoon snacks of the
Sugar and Salty variety as well as soft drinks. Lead by example, no goodies in the dorms, we do not want any
Critters joining you in your sleeping bags, or the camper’s. (You will be the first one they wake up when
Screaming for you to get it out.)
No use of the washer or dryer so keep your messes to minimum if you need to wear your jeans more than
One day. (Not many people own 10 pairs of jeans to wear clean pair every day. Be sure to tell this to your
Campers as well, some of the new campers to the family will need you to help them along with everything
Until they get the swing of things)
Bedtime Sunday thru Thursday is at 9:30pm
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You will eat with your campers until further notice, if all goes well we can ease up on this rule towards end of
Week.
Be aware, if for any reason something is seen as inappropriate, wrong or illegal I will not hesitate to call parents.
You may bring your cell phones, but you will need to check them in with First Aid Office before campers
Check in. Your camper’s are not to have cell phones either, if you have a camper that has one please alert
Staff immediately.
Pranks:
 All Pranks MUST be approved by the Extension Agent (AKA: Curt). No exceptions!
 Or Horse Camp Coordinator if Curt not available.
Camper Gifts:
o Please remember to welcome your campers with gifts. A gift bag or basket is great. Some ideas:
o Sunscreen, cards, chap stick, games, bubbles, water guns, water balloons, cool lanyards(must be
breakaway kind if warn at camp), bandanas, water flavoring for water bottles, postcards with stamps or
stationary to write home, or anything else you can think of you wanted at camp.
Stranger Danger:
o All strangers must check in at the nurse’s office. They all will have a visitor’s pass.
o If any counselor or staff is concerned about someone on camp property they must call the coordinator
via radio so that he/she can approach said individual regarding their purpose for being on property.
There is no instance where you are to approach strangers on the property.
o In case of stranger on camp property, there will be an alert over the radio where all counselors must
collect all of their campers to make sure they know exactly where each and every camper is at time of
the alert. The counselor will keep campers in a safe location until alert is over.
o If camper is missing an additional alert must be radioed out to Coordinator who will then decide if
authorities must be called.
o Counselors must go to the restroom at night with their campers.
o Counselors must go with someone to the restroom at night. No one goes alone. No Exceptions.
MUSTS, MUSTS, MUSTS
Make sure your campers are safe on and off their horses. Never adjust any tack with a camper on the horse.
Campers must always have on their helmets when at the barn and their horse is out. Helmet may be removed
once the horse is in its stall.
Dress code will be enforced
Inappropriate relations with other counselors or campers will result in being sent home
Follow the general rule of good conduct.
Have a good spirit, be happy, and energetic, this will pass on to your campers.
Be responsible, efficient and prompt
Be prepared for your duties, know what you have to do and when.
Be respectful to others and expect it in return.
See things from others point of view.
Everyone can do something well… encourage that...
Show positive reinforcement
Appreciate others for their time and knowledge
Go over daily events with your campers
Know the emergency procedures dehydration, fire drills, bees, etc.
Inform campers of kitchen and bathroom duties. If you dismiss your campers from duties, you the counselor will
be responsible for making it right.
Make sure all campers have their name tags on at all time. (Water bottles will be with camper at all times too.)
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MUSTS, MUSTS, MUSTS CONTINUED
Be on top of problems before they escalate.
Be honest with yourself, others and us!!!!!!
Helpful Hints
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Arrival – be at camp on Saturday June 21st by 9:00am. We will be setting up the kitchen and getting
the camp ready for your campers to arrive on Sunday.
Bring clothes to clean the dorms and bathrooms. You will be working with bleach.
Getting stuff out of the trailer for the kitchen and nurse’s office.
Setting up the pig showers.
Helping the Gophers set up Pens.
Inspecting stalls, putting up signs/taking down signs.
Helping with camper check-in/departure.
Departure- You will need to stay an extra day at camp. You will need to help clean up after camp.
Departure date: Sunday June 29th.
Clean dorms and bathrooms with bleach.
Pick-up trash on all of premises.
Pack up kitchen and nurse’s office.
Organize and put things back into trailer.
Inspect all campers’ stalls. Make sure all signs are down.
Help campers pack up there belongings and clean out their stalls.
Campers – don’t’ loose them. Make them feel special, get to know them.
Fun – I want all of your to have fun, and in return your campers will have fun. Think of fun ways to turn
any situations into something positive.
Safety – remember any situation can turn into something dangerous. We need to be proactive, stop it
before it happens. If a situation does arise, deal with it to the best of your ability; get help as soon as
possible. Use your radio!!!!
Campers must have helmets on if horse is out of stall.
Do not adjust bridles with camper on horse.
Have trainers or gophers help with problem horses. Inform barn manager (Diane) immediately.
Informed – keep us informed of any problem in behavior, attitude, eating habits, personal hygiene or
sleeping problems. We will work together to come up with a solution.
There will be a counselor’s meeting each night at 9:00pm. We will discuss the day, brainstorm solutions
to problems and set goals for the next day.
If problems arise that cannot wait until the nightly meeting please let Kelly or Patty know ASAP so they
can help trouble shoot any issues. Camp is supposed to be fun for all. Do not be afraid to ask for help.
Education – our goal is to have every camper leaving camp knowing more than when they arrived. This
can apply not only for horses but for life skills a well, this is where being a good role model comes in.
Prevention – home sickness, sunburn, and dehydration, these are all things that can be prevented Look
for signs.
Keep a positive attitude to prevent home sickness. Ask for help is someone seems sad. Find them a
friend.
Be a role model, put sunscreen on often and drink lots of water.
Make sure no sun screen, perfume, lotions or anything with a smell is sprayed in the dorms! This
could cause an allergic reaction or an asthma attack!!
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Downtime – you need it and so do your
campers. Make use of time without activities to rest. Lights
our means SLEEP. That sun comes up awfully fast. We don’t want to have cranky campers, counselors
or directors.
Departure – you may leave on Sunday, after the grounds and the surroundings have been cleaned and
inspected. If you have siblings there being picked up, and that is your ride home as well, make sure
they know you cannot leave until WE say so. We appreciate everything you are going to be doing for
your campers and for staff. You are a big help to us (Patty and Kelly). We look forward to many years of
Horse Camp together...
Trainers- Remember that you are the trainers assistants. They count on you helping your kids and the
other kids!