A lot has happened in the last few months to keep us all busy in 4-H.

Thank you to everyone who participated in any National 4-H Week activities. Everything you did helped to promote 4-H to your community and to the county.

Achievement Day was recently held. Many 4-Hers were recognized for their outstanding accomplishments. Also, records were turned in and judged. Your records have been returned to your leaders, and you should get them back soon. Take note of the judges' suggestions because it is time to get started for next year!

Leaders Banquet was also recently held. Thank you to Kelley Koester and Codie Geisz for their leadership in organizing this event!! When you get a minute, it might be really nice to tell your leaders "thank you" for all they do. It would be impossible to have the strong 4-H clubs without them!!

Please mark your calendars so you will remember the many events, activities and deadlines for the next few months. Look for more information in this newsletter and upcoming newsletters regarding some of these events.

As always, keep working hard, have fun, and have a Happy Thanksgiving, a Merry Christmas, and a Happy New Year!!

Peter

- Peter Morhardt

November

26-27 - Happy Thanksgiving - Office Closed

December

1 – Leader's Meeting – 7 p.m. – Extension Office

1 - LCP Award Applications Due to Extension Office – 4:30 p.m.

7 – Federation Meeting – 7 p.m. – Elizabeth Community Building

24-31 – Merry Christmas – Office Closed

January

1-3 – Happy New Year – Office Closed

4 – Federation Meeting – 7 p.m. – Elizabeth Community Building

4 – Records to be sent for state Recognition for Excellence due to Extension Office

15 – Postmark deadline to re-enroll in 4-H and sign up for most animal projects

17 – Federation Ski Trip – 4-9 p.m. – Chestnut Mountain Resort, Galena

18 – Martin Luther King Jr. Day, Office Closed

February

6 - Beef Weigh-In – 11a.m.-2p.m. – Elizabeth Community Fairgrounds

12-13 – The Great 4-H Debate – Springfield

12-13 – 12-14 Conference - Nauvoo

13 – Poor Weather Back-up Date for Beef Weigh-In – time and place the same as Feb.6^th

20-21 – Junior Leadership Conference – Carlinville, IL

March

1- Deadline for enrollment in dairy projects

13 – Horse Bowl Contest, Ogle County (Leaf River)

26-27 – Federation Lock-in, 10 p.m.-6 a.m., Freeport YMCA

April

1 – Deadline for new 4-H member enrollment

15 – Deadline for all other 4-H projects

I'm sure no one has forgotten about the 4-H Program Fee, but just to refresh everyone on what the policy and procedures are going to be for the collection of this fee. As you know, the 2009-2010 4-H Program Fee is required in order to be a community club member or a Cloverbud member. That fee is $20/person for the 2009-2010 4-H Year. Due to sponsorships from a couple of organizations, $15 of the $20 fee has been covered; this means each person is still responsible for $5 of the $20. The clubs may or may not pick up any or all of the remaining amount. Therefore, we are sending out a form to each of the club organizational leaders to have them tell us how much their club can or cannot support the remaining $5/member. For those clubs who cannot support the remaining amount, the Extension office will be sending out invoices to each 4-H member or family for the remaining $5. If you do not pay it, you will not be able to show at the 4-H Fair, unless paying the remainder of the fee causes a financial hardship on you or your family, please contact the office, and we have a form that you can fill out to help pay for that remaining amount.

We will be having a leader's meeting on December 1^st at the Extension office. Some of the items to be discussed will be the 4-H Program Fee, enrollment/re-enrollment deadlines and concerns, and upcoming events.

Once again, the State 4-H Office is offering the VALUED Volunteers program. The Orientation Series is six modules, while the Training Series consists of 4 topics. Any leader who is interested in learning more about these opportunities, please contact the Extension Office.

The results for Jo Daviess County from the 2009 Illinois State Fair are in this newsletter.

Also, we have just received the premium checks from state fair, and you should be receiving them shortly. Please cash them quickly after you receive them, as they are only good for 6 months. Thank you!!

The Illinois Farm Bureau and their Affiliate Companies offer a wonderful opportunity for 4-H members ages 17 and above to be recognized for their involvement in the 4-H program. The 4-H Premier LCP Award provides several levels of recognition to applicants. Each county may submit two entries. Ten 4-H members with the highest cumulative point totals receive state recognition at the Illini Summer Academies and ten 4-H members receive the opportunity to attend the IFB Premier 20 Leadership Conference in April.

Applications are now available through the Extension office. Applicants must be 4-H members who are at least 17 years of age by December 1, 2009. The applications are due to the office by December 1, where they will be judged. Up to two applications will be on sent to state competition.

The National 4-H Conference is a working conference where delegates attend workshops and discuss issues to suggest future programming for 4-H on a national, state, and local basis. The delegates also spend one day discussing the impact of 4-H with their federal legislators. As a part of this conference in Illinois, the delegation is committed to work on a special project for one year. This project can be a continuation of a previous year, or it can be a new project from the delegation.

4-Hers who are interested must be between 15-18 years of age. If you are interested, please contact the Extension office for more information, as the deadline to turn in this application is December 7^th. You are NOT guaranteed a place on this trip; Illinois 4-H Youth Leadership Team members take first priority for National 4-H Conference. The fee for this conference, if you are accepted to attend, is $350. Keep in mind that Federation may help cover some of the registration fee. Cori Elliott may be a person to contact about this conference, as she was part of the Illinois delegation in 2008.

The 2010 Junior Leadership Conference is set for February 20-21 at Lake Williamson Camp & Conference Center near Carlinville. If you are interested in attending this event, please contact the Extension office. The fee for the conference this year is $98; however there is a discount to $93/person if there are 4 or more 4-Hers from the unit. Registration is online ONLY and will be open until January 25^th. If you would like to apply for a scholarship, that deadline is January 8^th. If you have questions about this conference, please ask Codie Geisz, Kelley Koester, or Corey Wachter, as all 3 attended this conference last year.

Citizenship Washington Focus (CWF) is yet another opportunity to view the inner workings of Washington, D.C. It is a weeklong program that will help you understand more about federal legislation, the political parties, and how to make a positive impact in your community, as well as how to handle yourself with Illinois congressional people. The fee for this conference is on the pricey side…$1,050 at least. However, it is a full week at Washington, D.C!! Again, keep in mind that Federation may help with part of the registration for this conference. If you are interested in more information on this trip, please contact the Extension office. Registrations will only be taken online, and are due by December 15^th!!

There has been a major change in how the Culture Kits are going to be handled from here on out. The State 4-H Office will no longer be directly working with the Culture Kits. The Culture kits are now housed in various different counties throughout the state. We do not have any in the Jo-Carroll Unit, as we do not have the space to store these kits. The closest kits are a couple of counties away. So, if you would like a specific culture kit, you need to contact the Extension office well in advance of your event, so we can try and work out some way of getting the kit(s) to Jo Daviess County.

The States 4-H International Exchange Program (S4-HIEP) has opportunities for 4-Hers to travel to three different countries: Japan, Australia, and Costa Rica. If anyone is interested in any of these exchange programs, the application is due on January 15^th. There also is a $900 non refundable deposit due on January 15^th. The total cost for these trips is $2500 to $5500, depending on the country. We have flyers on each of these exchange programs here at the office, if you are interested in more information.

You must meet these project enrollment deadlines in order to show at the fair.

January 15: all beef, dairy, goat, horse, sheep, and swine projects

April 15: all other projects not previously listed

May 1: horse lease forms

Please note the change in these dates!! These are postmark deadlines, meaning they will not change unless that day lands on a weekend or holiday (deadline will be the following business day if that occurs).

For those of you who love to hunt, the Illinois 4-H Program has received approval to start a 4-H Shooting Sports program. In order to have 4-Hers involved with Shooting Sports in Jo Daviess County, we need some adult volunteers to step up and take a training course. So, if you know of any adult who would be very good at working with youth in dealing with Shooting Sports, please have them call the Extension Office. While I have not put much of this information in the newsletter in the past, we have had some information stating this would be happening, and the first couple of trainings have been held this fall. I know of at least one for this spring at the Memorial 4-H Camp in Monticello, and there may be an opportunity for a training session somewhere in the northern part of the state. If you, or someone you know is interested, please let us know at the Extension Office as soon as possible, so we can make sure all the steps are followed. Thank you!!

The Leaders Banquet was held on Wednesday, November 4^th at The Cove at Apple Canyon Lake. Turnout was good, and we had several leaders reach milestones. Those leaders reaching special milestones include:

1^st year – Leisa Hubb

5^th year – Elaine Elliott

10^th year – Goldie Foley

15^th year – Janet Swift

45^th year – Elizabeth Schnitzler

65^th year – Elda Goodmiller

For those clubs who did not have any leaders that were able to make it, we have your certificates and gifts at the Extension office. Please stop by sometime and pick those up, or I can give them to you at the leader's meeting. Congratulations to all of the leaders for volunteering so much to the Jo Daviess County 4-H Program!!

The Jo Daviess County 4-H Federation is once again sponsoring a ski trip for all 4-H members, their families, and one guest/member. This ski trip will be held January 17^th, 2010 at Chestnut Mountain Resort outside of Galena. The skiing will start at 4:00 p.m., and will continue until 9:00p.m. More information is on the back cover in terms of packages and cost. Please note that the Federation has changed the pricing strategy around somewhat from past ski trips. Just to give you some idea of how good a deal this is, the cost for a single person to purchase a lift ticket, ski or board rental, and a group lesson is about $70. Also, I need a medical form and a release from risk and liability form for each person attending. Please do not put multiple youth on the same form. If you need more forms, please contact the Extension office, and we will send you more. Any adult who is attending, there is a separate medical form different from the youth medical you must fill out (it looks the same, but has a few differences). Please contact the Extension office and we will send that form out to you. We may also have these forms on the internet, if Sandy can put them on, or if I get access to put them on the internet (but, I make no promises on this one!!).

The Jo Daviess County 4-H Federation is once again sponsoring a ski trip for all 4-H members, their families, and one guest/member. This ski trip will be held January 17^th, 2010 at Chestnut Mountain Resort outside of Galena. The skiing will start at 4:00 p.m., and will continue until 9:00p.m. More information is on the back cover in terms of packages and cost. Please note that the Federation has changed the pricing strategy around somewhat from past ski trips. Just to give you some idea of how good a deal this is, the cost for a single person to purchase a lift ticket, ski or board rental, and a group lesson is about $70. Also, I need a medical form and a release from risk and liability form for each person attending. Please do not put multiple youth on the same form. If you need more forms, please contact the Extension office, and we will send you more. Any adult who is attending, there is a separate medical form different from the youth medical you must fill out (it looks the same, but has a few differences). Please contact the Extension office and we will send that form out to you. We may also have these forms on the internet, if Sandy can put them on, or if I get access to put them on the internet (but, I make no promises on this one!!).

The 2010 Horse Bowl will be held at Leaf River in Ogle County on March 13^th. Please mark that day on your calendar if you are interested in attending this event. Also, please call the Extension Office if you are interested, and we will work on putting a team together.

Name Hometowm Division Class Rating

Jessica Albrecht Elizabeth Visual Arts Paper S

Laura Albrecht Elizabeth Visual Arts Metal A of E

Lucas Albrecht Elizabeth Woodworking Woodworking II A of E

Ellen Bonvillain Stockton Visual Arts Chalk/Carbon/Pigment A of E

Erin Brashaw Galena Visual Arts Clay S

Amber Bratcher East Dubuque Citizenship Public Adventures-Club S

Abby Cassens Stockton Health Keeping Fit III A of E

Ashley Cassens Stockton Interior Design Design Decisions-Beginning A of E

Emily Curtiss Stockton Clothing & Textiles Sewing & Textiles II A of E

Abagail Davis Scales Mound Fashion Revue Fashion Revue A of E

Becky Duchow Stockton Intergenerational Walk In My Shoes - Indiv. A of E

Randy Duchow Stockton Communications Communications III S

Zane Elliott Stockton Electricity Elect. III-Wired for Power S

Lisa Foley Scales Mound Child Development Clover Chal-Child Development S

Codie Geisz Elizabeth Horticulture Horticulture Display A of E

Riley Hepperly Elizabeth Electricity Elect. III-Wired for Power A of E

Leah Holland Scales Mound Photography Photography 2 A of E

Kyle Hubb Stockton Crops Soybeans A of E

Amber Kickbush East Dubuque Photography Photography 3 A of E

Connor Kickbush East Dubuque Visual Arts Wood S

Kelley Koester Elizabeth Health Keeping Fit II-Staying Healthy S

Nathan Koester Scales Mound Animal Science Animal Science A of E

Alan Myelle Scales Mound Visual Arts Heritage Arts A of E

Elizabeth Myelle Scales Mound Photography Photography 3 A of E

Rachel Schiess Scales Mound Interior Design Design Decisions-Intermediate A of E

Jennifer Schoenberger Cuba City Citizenship Public Adventures-Club S

Jacqueline Swift East Dubuque Citizenship Public Adventures-Club S

Kyle Theill East Dubuque Citizenship Public Adventures-Club S

Austin Wachter Elizabeth Woodworking Woodworking IV S

CoreyWachter Elizabeth Visual Arts Glass/Plastic A of E

National 4-H Congress Winners

Allison McLane - Achievement

Jessica Albrecht – Achievement

These two 4-Hers will be traveling to Atlanta, GA to attend National 4-H Congress. These 4-Hers earned this trip for their outstanding work in 4-H and their records.

National 4-H Dairy Conference Winner

Elizabeth Myelle

Elizabeth had the opportunity to attend the National 4-H Dairy Conference held in Madison, Wisconsin in early October; however she had other obligations and was unable to attend. She earned this trip because of her outstanding work in 4-H and her records.

"I Dare You"Award Winners

Jessie Albrecht

Ellen Bonvillain

Valerie Girot

Austin Wachter

Blue Award Winners

The State Blue Award is presented to the 4-H members whose project records have finished in the top 10% at the State Record Judging Contest. This year we had a number of winners. They are:

Elizabeth Myelle – Animal Sciences, Dairy

Jessica Albrecht – Achievement

Allison McLane – Achievement, Animal Sciences, Community Involvement & Global Awareness, Environment & Natural Resources, and Food, Nutrition & Health

Club of the Year

Scales Mound

Outstanding 4-Her Award Winners

Allison McLane

Elizabeth Myelle

Congratulations to all of the winners!! Just as a reminder, please send thank you cards/notes to ALL of your donors for any and all of your awards!! Thank you!!

Please Cash your Jo Daviess County 4-H Fair Premium Checks!!!!! If you did not receive your check, please call the Extension Office IMMEDIATELY!!!!!

September 1 is the date for determining eligible ages to enroll in 4-H.

To be eligible the youth must be 8 years old or in 3^rd grade by Sept. 1, 2009 and no older than 18.

Cloverbuds must be 5 years old by September 1, 2009

JO DAVIESS COUNTY 4-H FEDERATION SKI TRIP

WHO: All 4-H Members, 4-H Families, and ONE Guest per 4-H Member

WHEN: Sunday, January 17,2010; 4:00 p.m. to 9:00 p.m.

WHERE: Chestnut Mountain Ski Resort

Meet at the Group Window area to receive tickets from Federation Officer/Staff

Package	Cost to 4-H Member or 4-H Family	Cost to Guest of 4-H Member
A: Lift Ticket, Ski or Board Rental & Free Group Lesson*	$20/person	$40/person
C: Lift Ticket & Lesson	$14/person	$28/person
D: Lift Ticket Only	$11/person	$22/person

*In Package A, the lesson can be exchanged for 2 runs on the NASTAR Course (Blackhawk).

Please make checks payable to: Jo Daviess County 4-H Federation

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SKI TRIP PARTICIPATION REGISTRATION/PERMISSION FORM

Return by: Wednesday, January 6, 2010

Participant Name 4-H Family Guest Package

(Please Print Legibly) (Please state 4-H Club) (Please state guest of (Choose A, C or D

which 4-H member) from list above)

Please Note: A completed and signed health form (both sides) and a completed and signed Agreement to Assume Risk and Release from Liability must accompany this form in order to be registered for this event!!

I give permission for my son/daughter to participate in the Jo Daviess County 4-H Federation Ski Trip at Chestnut Mountain Resort on January 17, 2010.

Parent/Guardian signature

Amount enclosed

Return to: Jo Daviess Extension, PO Box 600, 204 Vine St, Elizabeth, IL 61028

UNIVERSITY OF ILLINOIS EXTENSION 4-H PROGRAM

YOUTH EMERGENCY MEDICAL INFORMATION

EVENT: ___Jo Daviess County 4-H Federation Ski Trip__________________________________________

PARTICIPANT'S NAME: _________________________________________________________________

Address: ________________________________________________________________________________

Street City State/Zip Code

Age: ____________ Sex: ________________ Date of Birth: __________/________/_________

PARENT/GUARDIAN/OTHER EMERGENCY CONTACTS:

Name: __________________________________________________________________________________

Relationship

Home Phone: _(______)_________-______________ Work Phone: _(______)_________-______________

Address: ________________________________________________________________________________

Street City State/Zip Code

Name: __________________________________________________________________________________

Relationship

Home Phone: _(______)_________-______________ Work Phone: _(______)_________-______________

Address: ________________________________________________________________________________

Street City State/Zip Code

HEALTH INFORMATION STATEMENT

Check below any information you feel staff and/or volunteers may need, to maximize the safety and the well being of the exhibitor or staff member. To the right of the condition statement is space for more information relating to the condition checked. Please be specific. In case of emergency, this health information may be the only source of accurate, important information.

[ ] Nervous or Mental (epilepsy, emotional stress, convulsions) _________________________________

_________________________________________________________________________________

[ ] Lung Disease (asthma, persistent cough, tuberculosis) ______________________________________

_________________________________________________________________________________

[ ] Disease of Heart or Blood Vessels, Increased or Abnormal Blood Pressure______________________ _________________________________________________________________________________

[ ] Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever) _________________________

_________________________________________________________________________________

[ ] Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis)

_________________________________________________________________________________

[ ] Arthritis, Diabetes, Kidney or Bladder Disease ___________________________________________

_________________________________________________________________________________

[ ] Hay Fever or Allergies ______________________________________________________________

_________________________________________________________________________________

[ ] Allergy to Medicines (including penicillin, tetanus) ________________________________________

_________________________________________________________________________________

[ ] Impaired Sight or Hearing, Chronic Ear Infections_________________________________________

_________________________________________________________________________________

[ ] Recent Surgical Operation, Accidents or Injuries_______________________________________

______________________________________________________________________________

[ ] Any Infectious Disease___________________________________________________________

______________________________________________________________________________

[ ] Skin Disease____________________________________________________________________

______________________________________________________________________________

[ ] Allergy to Foods________________________________________________________________

______________________________________________________________________________

[ ] Currently taking Medicines (list names & doses) _______________________________________

______________________________________________________________________________

[ ] Medication that needs refrigeration _________________________________________________

______________________________________________________________________________

[ ] Under on-going care of a Physician (NAME & PHONE #) for chronic or recurring problem

______________________________________________________________________________

[ ] Do you wear glasses? YES[ ] NO [ ] SOMETIMES[ ]

[ ] Do you wear contact lenses? YES [ ] NO[ ] SOMETIMES [ ]

[ ] Date of last TETANUS BOOSTER_________________________________________________________

[ ] Date of last FLU SHOT __________________________________________________________________

[ ] Significant Orthopedic and/or Neuromuscular Impairment (e.g. loss of limb, spinal cord injury)

______________________________________________________________________________________

Primary Care Physician: _______________________________________________________________________

Clinic/Hospital Affiliation: _______________________________________________________________________

City: _____________________________State: ______________Phone: _(____)_____-______________________

Health Insurance Provider: _____________________________________________________________________

Owner's Name: ____________________________________ ID/Policy Number: ___________________________

Medical Privacy Statement: It is the policy of University of Illinois Extension 4-H Youth Development Programs to keep any medical information it may have regarding 4-H Youth Development program participants confidential. However, there may be time in which such medical information will be needed and may need to be shared with others. Examples of sharing might include: providing information to medical personnel in the event of an emergency so that a youth may be treated; providing information to Extension staff or volunteers who are coordinating specific events in the case of a request for reasonable accommodation; and providing information to chaperones or host families who are responsible for the health and safety of program participants at a specific event. Except in the case of emergency, prior to sharing any medical information, it may have with those external to the University, Extension, or 4-H, every effort will be made to get the permission of the program participant or parent or guardian.

As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given. I further understand that in case of serious illness/injury, I will be notified. However, if it is impossible to contact me, I give my permission for emergency treatment, x-ray or surgery, as recommended by an attending physician.

I also understand that any accident insurance in effect (IF PROVIDED) for the event does not cover pre-existing conditions or self-inflicted injuries.

SIGNED:­____________________________________________________ DATE:__________________________

Parent or Guardian

Revised 7/03

Issued in furtherance of Cooperative Extension Work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, D. R. Campion, Director, University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension provides equal opportunities in programs and employment. *The 4-H Name and Emblem are Protected Under 18 U.S.C. 707.

UNIVERSITY OF ILLINOIS EXTENSION 4-H PROGRAM

ADULT EMERGENCY MEDICAL INFORMATION

PARTICIPANT'S NAME: _________________________________________________________________

Address: ________________________________________________________________________________

Street City State/Zip Code

Age: ____________ Sex: ________________ Date of Birth: __________/________/_________

EMERGENCY CONTACTS:

Name: __________________________________________________________________________________

Relationship

Home Phone: _(______)_________-______________ Work Phone: _(______)_________-______________

Address: ________________________________________________________________________________

Street City State/Zip Code

Name: __________________________________________________________________________________

Relationship

Home Phone: _(______)_________-______________ Work Phone: _(______)_________-______________

Address: ________________________________________________________________________________

Street City State/Zip Code

HEALTH INFORMATION STATEMENT

Check below any information you feel staff and/or volunteers may need, to maximize the safety and the well being of the exhibitor or staff member. To the right of the condition statement is space for more information relating to the condition checked. Please be specific. In case of emergency, this health information may be the only source of accurate, important information. This information will be kept confidential unless needed in case of illness or injury and can be returned after the program is concluded.

[ ] Nervous or Mental (epilepsy, emotional stress, convulsions) _________________________________

_________________________________________________________________________________

[ ] Lung Disease (asthma, persistent cough, tuberculosis) ______________________________________

_________________________________________________________________________________

[ ] Disease of Heart or Blood Vessels, Increased or Abnormal Blood Pressure______________________ _________________________________________________________________________________

[ ] Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever) _________________________

_________________________________________________________________________________

[ ] Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hernia, colitis)

_________________________________________________________________________________

[ ] Arthritis, Diabetes, Kidney or Bladder Disease ___________________________________________

_________________________________________________________________________________

[ ] Hay Fever or Allergies ______________________________________________________________

_________________________________________________________________________________

[ ] Allergy to Medicines (including penicillin, tetanus) ________________________________________

_________________________________________________________________________________

[ ] Impaired Sight or Hearing, Chronic Ear Infections_________________________________________

_________________________________________________________________________________

[ ] Recent Surgical Operation, Accidents or Injuries__________________________________________

_________________________________________________________________________________

[ ] Any Infectious Disease_______________________________________________________________

_________________________________________________________________________________

[ ] Skin Disease_______________________________________________________________________

_________________________________________________________________________________

[ ] Allergy to Foods____________________________________________________________________

_________________________________________________________________________________

[ ] Currently taking Medicines(list names & doses) __________________________________________

_________________________________________________________________________________

[ ] Medication that needs refrigeration _____________________________________________________

_________________________________________________________________________________

[ ] Under on-going care of a Physician (NAME & PHONE #) for chronic or recurring problem

_________________________________________________________________________________

[ ] Do you wear glasses? YES[ ] NO [ ] SOMETIMES[ ]

[ ] Do you wear contact lenses? YES [ ] NO[ ] SOMETIMES [ ]

[ ] Date of last TETANUS BOOSTER_____________________________________________________

[ ] Date of last FLU SHOT _____________________________________________________________

[ ] Significant Orthopedic and/or Neuromuscular Impairment (e.g. loss of limb, spinal cord injury)

_________________________________________________________________________________

Primary Care Physician:___________________________________________________________________

Practice/Clinic/Hospital Affiliation: ___________________________________________________________

City: _______________________________State: ____________Phone: _(____)_____-_________________

Health Insurance Provider: ________________________________________________________________

Owner's Name: _________________________________ ID/Policy Number: _________________________

Medical Privacy Statement: It is the policy of University of Illinois Extension 4-H Youth Development Programs to keep any medical information it may have regarding 4-H Youth Development program participants confidential. However, there may be time in which such medical information will be needed and may need to be shared with others. Examples of sharing might include: providing information to medical personnel in the event of an emergency so that an adult may be treated; providing information to Extension staff or volunteers who are coordinating specific events in the case of a request for reasonable accommodation; and providing information to chaperones or host families who are responsible for the health and safety of program participants at a specific event. Except in the case of emergency, prior to sharing any medical information, it may have with those external to the University, Extension, or 4-H, every effort will be made to get the permission of the program participant or parent or guardian.

To my knowledge, I have no health problems, unless stated above, and can SAFELY PARTICIPATE in the Jo Daviess County 4-H Federation Ski Trip and that I have no contagious or communicable disease. In case of emergency while participating in this event/program, I give permission for physicians to perform needed treatment. I will assume all financial obligations incurred if not covered by insurance.

SIGNED: ­_________________________________________________ DATE: _______________________

Participant

Return to: Jo Daviess County Extension

Attn: Peter Morhardt

204 Vine St., PO Box 600

Elizabeth, IL 61028

Revised 7/03

Issued in furtherance of Cooperative Extension Work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, D. R. Campion, Director, University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension provides equal opportunities in programs and employment. The 4-H Clover Name and Emblem are Protected Under 18 U.S.C. 707.