2015 National 4-H Shooting Sports Teen Leadership Institute
August 4 - 8, 2015
California State University, Fresno
Application Packet
Deadline – May 15, 2015 to your 4-H Shooting Sports State Coordinator
Please prepare a complete application packet and mail or email your application to your state 4-H Shooting
Sports Coordinator. State Coordinators will select two applications, identify one as the primary candidate and
one as the secondary candidate and forward the two applications to Lisa Muzzey, National 4-H Shooting Sports
Committee. The secondary candidate will be accepted depending on space availability. Applicants must be at
least 15 years of age by January 1, 2015 to apply. It is recommended that the candidates also have at least one
year left in 4-H.
All lodging (including linens), meals, transportation during the event and materials will be provided by generous
donations from the National 4-H Shooting Sports Steering Committee General Fund. The cost and
arrangement of transportation to the event will be the responsibility of the participant.
Participants should plan to arrive between 2:00 - 8:00 p.m. on Tuesday August 4, 2015. The event will
conclude on Friday evening August 7, 2015. Youth will depart campus between 7:00 a.m. – 10:00 a.m. on
Saturday, August 8, 2015. Transportation to and from the Fresno Yosemite International Airport is provided.
A completed packet includes the following:
1.
2.
3.
4.
5.
6.
7.
Letter of reference from your state 4-H SS Coordinator (done after state selection)
Resume for Teen Applicant - include school, 4-H, community memberships, activities and awards
California 4-H Member Code of Conduct Form
California 4-H Medical Treatment Authorization Form
California 4-H Waiver of Liability, Assumption of Risk, and Indemnity Agreement Form
National 4-H Shooting Sports Youth Leadership Institute Application Form
National 4-H Shooting Sports Youth Leadership Institute Certification Form (complete with all
signatures)
8. One 5 x 7 – Portrait Color Photograph and Digital Copy (jpeg or tif)
Send completed application packet to:
Gerry Snapp
1110 S. College Ave
Columbia, MO 65211
(573) 882-5547
Due to State Coordinator by May 15
Due to Lisa Muzzey – National 4HSS – June 1
Selection confirmation by June 15
University of California, Division of Agriculture & Natural Resources 4-H Youth
Development Program
Member Code of Conduct
The 4-H Policy Handbook tells me my rights as a 4-H member, and the rules I have to follow. 4-H calls the most
important rules for members the “Code of Conduct”. When members follow the Code of Conduct, it helps keep 4H safe and fun for everyone.
I will follow the 4-H Code of Conduct (rules) and I will:
1. Be nice, kind, helpful, and respectful to other 4-H members; and to adult volunteers, youth leaders, 4-H staff, and
other adults in charge.
2. Be honest, honor my commitments, and accept responsibility for my choices.
3. Use language that is respectful and kind. Not use curse words.
4. Wear appropriate clothes that are allowed by 4-H rules.
5. Not have or use alcohol, tobacco (like cigarettes, e-cigarettes, or chew) or other drugs (unless my doctor gives
them to me).
6. Not bother or attack others, not carry or use a weapon; and not do anything else illegal or unsafe.
7. Know that adults can search my things (like my backpack) if they think I might have broken the 4-H rules.
8. Not touch anyone in a way that is too affectionate, and not engage in sexual behavior.
9. Follow the 4-H Guidelines for Social Media - http://www.ucanr.edu/files/133821.docx.
10. Not do things outside of 4-H that are harmful to anyone in 4-H or the 4-H program.
While attending 4-H overnight events I will:
1.
2.
3.
Be in my room when I’m supposed to be there.
Not leave the grounds unless an adult in charge gives me permission, and only if there are two adults with me.
Not be in the girls’ sleeping area if I’m a boy, not be in the boys’ sleeping area if I’m a girl, and not invite any kids
who aren’t 4-H members into the sleeping areas.
Be responsible for any damage caused by my actions.
Follow all the rules for that event.
4.
5.
Consequences
Anyone who sees someone break the Member Code of Conduct should tell the adult in charge right away. That
adult will tell that member’s parent or guardian. Consequences for breaking the 4-H rules may include:
1. Sending the member home.
2. Having the member meet with 4-H adults, talk about how the member can learn from what they’ve done, and
decide what the member should do to make up for any harm done.
3. Charging the member (or their parents/guardians) for the cost of repairs to property that the member damaged.
4. Giving the member a warning, barring them from future events, suspending their membership, or terminating their
membership.
5. Taking the member to the nearest law enforcement agency or other proper authority.
Photograph and Information Release
I give to The Regents of the University of California, National 4-H Council, National 4-H Headquarters (USDA),
Cooperative Extension and units, its nominees, agents, and assigns, unlimited permission to copyright and use,
publish, and republish for purposes of advertising, public relations, trade, or any other lawful use, information
about me and reproduction of my likeness (photographic or otherwise) and my voice, whether or not related to
any affiliation with 4-H, with or without my name. I hereby waive any right that I (and minor) may have to
inspect or approve the copy and/or finished product or products that may be used in connection therewith or the
use to which it may be applied.
County:
Signature of Member:
Date:
Signature of Parent/Guardian:
Date:
Form Revised 7/1/2014
Youth Treatment Authorization Form
This Treatment Authorization Form is authorized for all 4-H Youth Development meetings and
activities during the dates specified below. (Note: This information must be updated annually)
First Name
Last Name
Club/Unit Name
From: August 1, 2015
to August 10, 2015
County and State
While my child is attending or traveling to or from this 4-H function, I HEREBY AUTHORIZE THE 4-H
ADULT VOLUNTEER OR 4-H STAFF MEMBER, or in his/her absence or disability, any adult
accompanying or assisting him/her, TO CONSENT TO THE FOLLOWING MEDICAL TREATMENT
FOR SAID MINOR:
Any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which
is deemed advisable by, and is to be rendered under the general or special supervision of any
physician and/or surgeon licensed under the provisions of the Medical Practices Act, California
Business and Professions Code Section 2000 et seq.; or any x-ray examination, anesthetic, dental or
surgical diagnosis or treatment, and hospital care to be rendered by a dentist licensed under the
provisions of the Dental Practices Act, California Business and Professions Code Section 1600 et
seq.
This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.
This authorization shall remain effective until my child completes his/her activities in this program
unless sooner revoked in writing. I understand that as a parent/guardian, I will be responsible for the
cost of any service or treatment provided not covered by the 4-H Accident/Sickness Insurance
Program sponsored by UC Cooperative Extension.
EMERGENCY CONTACT INFORMATION
Name
(
Relationship to Youth Identified Above
)
Emergency Day Phone (with area code)
Mailing Address
(
)
Emergency Night Phone (with area code)
City
State
Zip
AUTHORIZATION AND CONSENT AND RELEASE
I hereby certify that my child is in good health and can travel to and participate in all functions of the 4-H Youth
Development Program as described above. I understand is it my responsibility to keep the information on this form
updated (including Health History) by contacting the County 4-H Office.
Signature of Parent/Guardian
Date
NON-CONSENT
I do not desire to sign this authorization and understand that this will prohibit my child from
receiving any non-life threatening medical attention in the event of illness or accident.
Signature of Parent/Guardian
Date
University policy and the State of California Information Practices Act of 1977 require the following information be provided when collecting personal information from you: The information entered
on this form is collected under authority of the Smith-Lever Act. Submission of the medical data is voluntary. However, a signature is required on one or the other of the two signature lines
above. Failure to provide the medical information and authorization may result in our inability to provide necessary medical treatment. You have the right to review University records containing
personal information about you, with certain exceptions as set forth in policy and statute. Copies of University policies pertaining to the collection, use, or release of personal data are available for your
examination from the local UCCE County Director, 4-H Youth Development Advisor, 4-H Program Representative or the Associate Director of 4-H Program & Policy at University of California, Division of
Agriculture and Natural Resources, California State 4-H Office, 2801 Second Street, Davis, CA 95618-7774, (530) 750-1334, [email protected]. Only your own records are open to your review.
Health History Information
/
First Name
Birth
Last Name
Subject to:
Colds
Sore Throat
Fainting Spells
Bronchitis
Convulsions
Cramps
Allergies
Wear corrective lenses?
Is hearing good?
/
County
YES
No
Date of
Now Have or Have Had
Heart Trouble
Asthma
Lung Trouble
Sinus Trouble
Hernia (rupture)
Appendicitis
Has appendix been removed?
Do you walk in your sleep?
Yes
Date of last Tetanus Vaccination:
Please check over-the-counter medications that may be administered:
Tylenol
Ibuprofen
Hydrocortisone
Cough Syrup
Other:
Decongestant
Dramamine
Antacid
Polysporin
Please identify allergies including allergies to food, medications, and drug reactions:
Please list any disability accommodations you will need in order to participate in this program or
activity.
Please list all current medications:
Name of Medication
Dosage
Times Taken
Please include any additional remarks and special instructions to better assist emergency
service personnel. Please explain “yes” answers on this page.
No
University of California, Division of Agriculture & Natural
Resources 4-H Youth Development Program
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Participant’s Name (Please Print)
County
Club/Unit
Waiver: In consideration of being permitted to participate in any way in California 4-H Youth
Development Activities and Projects, I, for myself, my heirs, personal representatives or assigns,
do hereby release, waive, discharge, and covenant not to sue The Regents of the University of
California, its officers, employees, and agents from liability from any and all claims including the
negligence of The Regents of the University of California, its officers, employees and
agents, resulting in personal injury, accidents or illnesses (including death), and property loss
arising from, but not limited to, participation in California 4-H Youth Development Activities and
Projects.
Assumption of Risks: Participation in California 4-H Youth Development Activities
and Projects carries with it certain inherent risks that cannot be eliminated regardless of
the care taken to avoid injuries. The specific risks vary from one activity to another, but the
risks range from 1) minor injuries such as scratches, bruises, and sprains; 2) major
injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and
concussions; and 3) catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these and other
risks that are inherent in California 4-H Youth Development Activities and Projects. I hereby
assert that my participation is voluntary and that I knowingly assume all such risks.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the
University of California HARMLESS from any and all claims, actions, suits, procedures, costs,
expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in
California 4-H Youth Development Activities and Projects, and to reimburse them for any such
expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing Waiver and
Assumption of Risk Agreement is intended to be as broad and inclusive as is permitted by
the law of the State of California and that if any portion thereof is held invalid, it is agreed
that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this Waiver of Liability, Assumption of Risk,
and Indemnity Agreement, fully understand its terms, and understand that I am giving up
substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely
and voluntarily, and intend by my signature to be a complete and unconditional release of all
liability to the greatest extent allowed by law.
Signature of Parent/Guardian of Minor or Adult Participant
Date Age (if minor)
THIS WAIVER APPLIES TO ALL CALIFORNIA 4-H YOUTH DEVELOPMENT ACTIVITIES AND PROJECTS INCLUDING, BUT NOT
LIMITED TO PROJECT MEETINGS, CLUB MEETINGS, EDUCATIONAL FIELD DAYS, FIELD TRIPS, CAMPS, EXCHANGE
PROGRAMS, FUNDRAISERS, COMMUNITY SERVICE ACTIVITIES, VOLUNTEER TRAININGS, FAIRS, AND PROJECTS.
DRAFT AGENDA
Meals will take place on campus except day of trip to Sequoia National Park.
Tuesday, August 4, 2015
2:00 – 8:00 p.m.
Arrive at Fresno between 2:00 p.m. and 8:00 p.m.
Lodging at dorms available for participants – check in: 2:00 – 8:00 p.m.
Pick up participants from airport
6:00 p.m.
Supper provided if on campus at this time
8:00 p.m.
Welcome activity/ice breakers & games led by participants
Wednesday, August 5, 2015
7:00 a.m.
Breakfast
8:00 a.m. – noon
E.D.G.E. Challenge Course (low & high element team building ropes course)
12:00 p.m.
Lunch
1:00 p.m.
Session # 1 Leadership Skills/Teamwork/Communication
3:00 p.m.
Group Photograph/Campus Tour/Bookstore Visit
4:00 p.m.
Session # 2 Self-Assessment
5:00 p.m.
Session # 3 Public & Private Value/Public Relations
6:00 p.m.
Supper
7:30 p.m.
Session # 3 Developing Your Story
Thursday, August 6, 2015
7:00 a.m.
Breakfast
7:30 a.m.
Depart for Sequoia/Kings Canyon National Park – Sack lunch will be provided
6:00 p.m.
Return to California State University, Fresno
6:30 p.m. approx.
Supper
Friday, August 7, 2015
7:00 a.m.
8:00 a.m.
10:00 a.m.
12:00 p.m.
1:00 – 3:00 p.m.
3:00 – 4:30 p.m.
4:30 – 5:15 p.m.
5:30 p.m. – 7:00 p.m.
7:30 p.m.
Breakfast
Session # 4 Public Speaking & Etiquette
Session # 5 Telling Your Story
Lunch
Developing Ambassador Plan
Sharing Ambassador Plans
Final remarks and certificates
Swimming Pool & Barbeque
Recreation at the Student Union
Saturday, August 8, 2015
7:00 a.m.
Breakfast – Morning gathering and depart California State University, Fresno by
10:00 a.m.
2015 National 4-H Shooting Sports Youth Leadership Institute
Application Form
Name:
Preferred First Name:
Address:
City:
State:
Home Phone Number:
Zip:
Cell Phone Number:_
Email Address:
County:
Club:
Date of Birth:
Years in 4-H:
Grade in School:
_
Age (as of Jan. 1 of current Year):
_
Grade Point Average (GPA):_
_
List Local Newspaper/Media Outlet:
Years in 4-H Shooting Sports (check those that apply):
Archery
Hunting
Muzzle loading
Pistol
Rifle
Shotgun
The following information is to assure that any clothing ordered for you will fit properly.
Polo Shirt Size:
T-Shirt Size:
2015 National 4-H Shooting Sports Youth Leadership Institute
Certification Form
I will be active in my club and county 4-H program, as well as maintain an acceptable academic
standard in school during my service as a 4-H Shooting Sports Ambassador. Further, I am willing
to conduct myself in the highest standards expected of an Ambassador.
Applicant’s Signature
Date
We (I) understand that our (my) son/daughter wishes to serve as a 4-H Shooting Sports
Ambassador. We (I) will support him/her in fulfilling the responsibilities should he/she be selected.
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
We certify that the above named 4-H’er is enrolled, active and in good standing in our 4-H shooting
sports club and county 4-H program. We support his/her application for the position of 4-H
Shooting Sports Ambassador.
4-H Club Leader Signature
Date
Extension Agent Signature
Date
State 4-H Shooting Sports Coordinator Signature
Date:
The University of California prohibits discrimination or harassment of any person on the basis of race, color, national origin, religion,
sex, gender identity, pregnancy (including childbirth, and medical conditions related to pregnancy or childbirth), physical or mental
disability, medical condition (cancer-related or genetic characteristics), ancestry, marital status, age, sexual orientation, citizenship, or
service in the uniformed services (as defined by the Uniformed Services Employment and Reemployment Rights Act of 1994: service in
the uniformed services includes membership, application for membership, performance of service, application for service, or
obligation for service in the uniformed services) in any of its programs or activities. University policy also prohibits reprisal or
retaliation against any person in any of its programs or activities for making a complaint of discrimination or sexual harassment or for
using or participating in the investigation or resolution process of any such complaint. University policy is intended to be consistent
with the provisions of applicable State and Federal laws. Inquiries regarding the University’s nondiscrimination policies may be
directed to the Affirmative Action/Equal Opportunity Director, University of California, Agriculture and Natural Resources, 1111
Franklin Street, 6th Floor, Oakland, CA 94607, (510) 987-0096.
National 4-H Shooting Sports Ambassador Program Guidelines
National 4-H Shooting Sports Ambassador Program is designed to promote 4-H and 4-H
Shooting Sports. Youth selected to serve as Ambassadors will receive training that will
allow them to return to their homes and advocate for the program at the county, regional,
and state level. Some Ambassadors may be asked to support national events as well.
Ambassadors provide public relations support at special events such as donor/sponsor
functions and also serve as spokespersons for the 4-H Shooting Sports Program, helping
to make 4-H and the 4-H Shooting Sports Programs more visible. The Ambassador’s
further develop their skills in leadership, public presentation, citizenship, community
service, public relations and team building.
PURPOSE, GOALS, OBJECTIVES
The 4-H Shooting Sports Ambassador program will provide a venue for 4-H Teens to:
1. Represent 4-H and specifically 4-H Shooting Sports for public relations purposes
at special events; at donor/sponsor functions and with the general public, 4-H
groups, community service organizations, schools and media contacts.
2. Serve as spokespersons for the 4-H Shooting Sports program at their respective
levels of participation – national, regional, state, county - helping to make 4-H
Shooting Sports programs more visible.
3. Further develop their skills in leadership, public presentation, citizenship,
community service, public relations and team building.
4. Assist in maintaining relations with 4-H Faculty and Extension Administrators
as well as past, present and future program donors and supporters.
5. Continue and expand their involvement in 4-H Shooting Sports beyond the shooting
skills and competitive events.
6. Stay actively connected with the 4-H Shooting Sports program as they enter their
collegiate years and further into adulthood.
PROGRAM EXPECTATIONS
By being selected as a National 4-H Shooting Sports Ambassador, you will be
representing over 320,000 4-H youth. What you say and do is very important.
Remember, you never get a second chance to make a good first impression. As an
Ambassador you may meet with donors who are CEO’s of companies or organizations
and you always need to put your best foot forward. The way you dress, the way you
speak and act are very important when you are serving as an Ambassador.
• You are expected to be on time, so plan to be early to any event.
• You need to respond promptly to any emails or phone calls from the Program
Coordinator and your chaperon for the event.
• It is very important that you send thank you notes immediately following the event.
You will be given names and addresses so that you can fulfill this obligation.
• You may get tired at events, but you always need to be cheerful and ready to
respond positively to everyone.
• A mature attitude and outlook is required.
• Ambassadors may be asked by your State Shooting Sports Coordinator or the
National Shooting Sports Committee to serve as a representative at a local,
regional, state, or national event.
BEHAVIORAL EXPECTATIONS
A goal of the 4-H Shooting Sports Ambassadors program is to provide opportunities for youth to
build character and develop their leadership skills. Ambassadors are expected to uphold the 4-H Code of
Conduct at all times.
DRESS CODE
Ambassadors are expected to dress in a manner befitting young men and women. Modesty,
neatness, well groomed and practicality will be the guiding principles. Attention to details is important, so
here are some tips for both men and women. Make sure you have:
•
•
•
•
•
•
•
•
•
clean/serviceable shoes and a pair of sneakers and comfortable clothing for the ropes course
well-groomed hairstyle
cleaned and trimmed fingernails
minimal cologne or perfume
no visible body piercing beyond conservative ear piercings for women
well-brushed teeth and fresh breath
no gum, candy, or other objects in your mouth
minimal jewelry
no body odor
Ambassadors are not to wear torn (intentional or otherwise) or sloppy clothing. Tank tops, muscle
shirts, bare midriffs, low necklines, sundresses, and tight or otherwise revealing clothing will not be
allowed. This applies to all spandex fashions. T-shirts with negative, outlandish, disrespectful messages
or pictures will not be allowed. Also, you are representing 4-H shirts with the logos of other youth
organizations should not be worn. Ambassadors are to have no visible tattoos.
Ambassadors may wear shorts and skirts of modest style and length. Shorts, skorts and skirts
may be no shorter than 3” above the knee. Females - Blouses/shirts must be tucked in when low-rise
slacks/jeans/skirts/ are worn. Males – Casual or dress slacks should be worn with shirttails tucked in. All
footwear should be clean, neat, shined and no flip flops.
We will have one evening with a swim party. Swim suit standards for males is swim trunks only (no
shorts, cut-off pants, or Speedos). Swim suit standards for females is one-piece suits are recommended;
however, two-piece suits are allowed as long as they are modestly cut. No string, thong, or crochet suits will
be allowed.
When serving as a National 4-H Shooting Sports Ambassador, you need to remember that
you are representing the 4-H Shooting Sports youth to the public and you need to make the best
impression possible.