SURVIVING CLOVERLEAF 4-H CAMP AT ROCK EAGLE - All You Ever Wanted to Know About July 6-9, 2021
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All You Ever Wanted to Know About
SURVIVING
CLOVERLEAF 4-H CAMP
AT ROCK EAGLE
July 6-9, 2021
(Plus a whole lot more!)
1
Cloverleaf Camp at Rock Eagle
We want to take this opportunity to thank you for
sharing your children with us for Cloverleaf Summer
4-H Camp. 4-H Camp is one of the most exciting and
memorable programs that we offer.
The Rock Eagle camping program has been offered to
thousands of Georgia 4-H’ers for over fifty years. It is
based on a Native American theme and the entire
facility is divided into three tribes: Shawnee, Cherokee
and Muskogee. Each tribe has a male and female
Mico, or leader. The tribes are overseen by leadership counselors with several years’
experience, known as the Tribal Council.
All week the campers will compete for points to win the Tribal Shield on Friday morning. Points
are awarded for clean cabins, keeping areas free of litter, being at classes on time, various
competitive activities, lights out at night and of course, on enthusiasm.
Tribes
We will be the Shawnee tribe, so you can pack clothing in tribe colors if
you want too.
BLUE, RED AND WHITE!
Cherokee: Orange, Black and White
Muskogee: Yellow, Red and Black
Shawnee: Blue, Red and White
Camp Activities Planned
Swimming Canoeing Archery Nature Hike to Rock Eagle Mound
Native Village & Canteen* Crafts & Canteen* HOP!/Outdoor Recreation
Herpetology OR Lake Ecology *canteen is the gift shop
2
Housing
This is a typical cabin layout, although the bathroom layout may vary. In Rooms 1, 3, 4, 5, & 6,
there will be two sets of bunk beds. Each room also includes its own bathroom. In 2021, each
room will hold 2 campers. Room 2 (ADULT ROOM) is furnished with two twin beds for adult
leaders with their own bathroom.
No toiletries, bedding or towels are provided for campers or adults.
Each cabin is air conditioned.
Every bed does have a pillow and a blanket.
All Walker County girls will be housed in one cabin, and next door will house all Walker County
boys. In 2021, a few Walker County girls will be housed with Mrs. Casey in another cabin with
another county of females.
Note: Do not use items that belong to another person.
Do not sit on another person’s bunk without asking permission first.
Only 1 person on a top bunk at a time.
Do not enter a room that is not yours.
Campers, remember to not touch the emergency windows and doors unless you are willing to
pay lots of money. Our cabins are equipped with rear door and window alarms (marked red)
and should ONLY be used in emergency situations. The alarm will sound and continue until a
camp staff person can disarm it. There is also a fee charged to the county and will be passed
onto the camper’s parents.
Check In on Tuesday July 6
Please arrive at 11:45am at the Walker County Extension Office (downtown LaFayette, 102 E.
Napier St., Across from the Walker County Department of Education) 706-638-2548
EAT LUNCH BEFORE YOU COME!
Tuesday morning will be controlled chaos checking in all
campers and loading luggage. Please check in with the
Extension staff INSIDE when you arrive. At check in, you will let
3
us know any changes on the medical forms and drop off your medication bag (do not pack).
Once you have checked in, you will be directed to load your luggage with another Extension
staff/ Camp Volunteer. Do NOT bring your luggage INSIDE, as it will be cramped.
Please remember typical bus rules including staying in your seat, keep the aisles clear, no body
parts out the windows. If you are prone to carsickness, please let us know and try to sit closer
to the front.
Nightly Tribal Meeting Suggestion
It is strongly suggested that campers take enough time prior to tribal meetings to quickly
change out of swimwear and into regular dry clothes for hygiene purposes.
Attendance
EVERYONE must attend all scheduled events. No one is allowed to stay behind in the cabin. If
they feel ill, then a leader will accompany them to the health cottage to see the nurse for
assessment. (If you do not want to touch a snake, and are assigned the snake class, you have to
attend the class, but they won’t make you touch a snake.)
Lights Out and Showers
After the counselor leaves, the campers need to shower as quickly as possible. It is important
for all campers to shower at night and QUICKLY! Campers may continue to shower after lights
out. At light out, all lights must be off, with the exception of the bathroom lights. The
bathroom may be propped open but no camera flashes, flashlights, etc. may be going off. It is
important for campers to have all their showering materials out and ready before lights out
while they can still have light to see. Lights out is strictly enforced.
Camp T-shirts
Included in your camp fee was a Walker County 4-H
Summer Camp t-shirt. Campers will receive their shirts on
Thursday night to wear on Friday.
4-H’ers will get the size parents ordered by the camp
application. All shirts are adult sizes.
NOTE: If you do not want your child to come home with
signatures on this shirt, please tell them before they leave
for camp. Hopefully, campers will have counselors and
other campers sign a pillowcase or paper, but inevitability, many will come home with their
camp shirts signed with permanent markers.
4
Medications and Medical Forms
You should have received a medical form and medication form. These papers need to be read
over WITH the 4-H’er before they are signed. Every 4-H’er and parent must complete a Medical
Form (This is your permission for the child to have prescription &/or over-the-counter drugs).
Camp leaders can administer basic first aid only. Children who cannot be treated through basic
first aid will be taken to the nearest hospital. Campers are covered with some 4-H health
insurance during the week of camp.
Over-the-counter medicine-If you want your child to have access to common OTC
drugs like Tylenol, Pepto Bismol, Neosporin, Benadryl, aloe for sunburns, etc. you
must package them in a zip-top plastic bag and label with the child’s full name. Bring
this bag INTO the 4-H office on Tuesday’s check in; do not pack in the suitcase. Indicate
on the form that you give your child permission to take these drugs and the dosage
instructions. Otherwise, 4-H leaders will have to obtain permission from you be phone
before we can give your child any over-the-counter drugs.
These forms are due by July 1, 2021. This will give us enough time to look over the information
and make all our leaders aware of any medication schedules of our campers. If a medication is
not written on this form, we will have to call a parent or emergency contact for permission to
administer the medication, whether it is just a headache or stomach ache. A nurse is available
24 hours a day on campus and a hospital is located nearby for emergencies.
Code of Conduct and Expectations
You should have also received a code of conduct verification email. If a 4-H’er is found in
violation of the rules, we will contact a parent/guardian to drive to Rock Eagle and take the 4-
H’er home.
WHAT HAPPENS IF I MISBEHAVE? We do not expect this to happen, but remember that
everyone signs a Code of Conduct before their departure. These rules will be enforced.
If the Code of Conduct is broken, it is the responsibility for the 4-H’ers parents to pick up
their child from camp, even in the middle of the night. 4-H’ers will be responsible for
repaying any damages while at camp.
4-H’ers will be expected to:
Abide by Georgia 4-H Code of Conduct
Help with daily cleaning (Make their bed, Put away clothing, Sweep, Mop, Take out trash)
Attend all classes, assemblies, and meetings
Be respectful of their cabin mates.
Keep your money and valuables in your suitcase.
Apply sunscreen several times each day.
Eat properly and drink lots of water
Come with a GREAT ATTITUDE!
5
Other Camping Guidelines and Rules
CELL PHONES
Cloverleaf campers will not be allowed to bring cell phones to camp. Cell phones will be
confiscated until the end of camp if they are discovered.
CLOTHING
Pack a daily change of comfortable clothing (some days you may need or want 2 outfits). Please
bring old clothes to play in and leave your nice new outfits at home. Shorts and t-shirts are
ideal. Keep these clothing guidelines in mind: halter tops, backless shirts, one shoulder tops,
shirts with spaghetti straps, tube tops, extremely tight clothing, visible midriffs, revealing pants,
or clothing that advertises alcohol or tobacco products are NOT allowed. Sleeveless shirts and
tank tops may be worn as long as they are modest, and girls’ straps need to be wide enough to
touch the shoulders or at least 1 to 2 inches wide. There should also be no visible cleavage or
visible undergarments (boys and girls). Boys must wear a shirt at all times except when in the
pool or participating in other water-related activities. Campers should also not wear shorts that
are too short or too tight. Generally, shorts need to be as long as the index finger when the
arms are extended by the sides.
SWIMWEAR
Girls must wear a one piece swimsuit or a tankini where top and bottom meets. They must be
in good taste, not skimpy, or too revealing. Bikinis or one piece swimsuits that are extremely
revealing (like those with the sides cut out) are not allowed. Tankini tops may not be worn with
bikini bottoms or vice versa. If you wear a swimsuit that does not meet the guidelines or is
deemed inappropriate by any adult leader at camp, you must wear a cover-up (a colored larger
t-shirt) during swim time. Girls need to pack a cover-up to wear to the pool or beach, or wear
the swimsuit under their clothes when they leave the cabin. Boys wear swim trunks. Any
camper or leader, male or female, may be asked to alter their swimming attire if deemed
inappropriate.
FLIP FLOPS
No “flip-flops” may be worn at 4-H summer camp. Comfortable shoes are a must. A pair of
tennis/athletic shoes is best for the walking you will do at camp! Wear socks to prevent blisters.
For some camp activities, tennis/athletic shoes are the only acceptable shoes. Comfortable
sandals and shoes with heel straps are ok; however, they must have a durable strap that is
attached to a sturdy shoe. Croc-type shoes are ok if the heel strap is worn on the heel, but
shoes that are merely flip flops with a thin heel strap are not appropriate for camp activities.
Flip flops can only be worn in the cabin. Shower shoes (like flip flops) are good to wear in the
cabin bathrooms, but these cannot be worn outside. Shoes must be worn at all times except
when swimming.
6
DO NOT BRING
· Knives · Balloons
· Radios · Fishing Equipment
· Video games (Gameboys, Nintendo DS, · Water Guns
PSP, etc.) · Excessive amount of cash or items of great
· CD players/ iPods/TVs/MP3s value (emotional or monetary)
· Cell phones · Food of ANY kind! (No gum, drinks, snacks,
· Shaving cream etc.)
· Perfume/Cologne · Anything that will get you in trouble
· Fireworks
**Please do not send your child to camp with something that you would be upset if they did
not come back home with. We are not responsible for any lost or stolen items. All items are the
camper’s responsibility. **
Other Clothing Tips
1. No clothing should be worn that violates the Code of Conduct.
2. Underwear should be worn at all times and should not be visible.
3. Camp is rough on clothes—bring only clothes that are okay to get wet or muddy.
4. Bring extra socks and underwear—you always need them!
Money
All meals, lodging, and a Walker County Camp t-shirt is included in the camp fee, however for
campers, $20.00 is probably a good amount to bring. Campers spend money for souvenirs and
snacks. DO NOT SEND OVER $40, these amounts tend to get lost within the first 24 hours.
Campers are responsible for their own money, they need to learn to be responsible to keep it
safe and out of sight. Please discuss this with your camper.
Meals and Importance of Eating Properly
Remember that no food, drinks or gum may be brought to camp. Meals are served cafeteria
style three times a day in our dining hall. Snacks will be available from the canteen that the
campers can pay for. NO FOOD IS ALLOWED IN THE CABINS. This will keep our fine creepy
crawlers from joining us in our beds at night.
Due to the extreme heat, PLEASE talk to your child about the importance of eating
meals and avoiding too many sugar-based drinks and junk food.
This is the cause of many illnesses at Rock Eagle.
7
Rise and Shine
Adults will be in charge of waking up the cabin, keeping in mind what must be accomplished in
order for the campers to have plenty of time to clean the cabins and eat breakfast without
rushing. Once campers leave the cabin, they are not allowed back into the cabin until much
later in the day. Campers will need to be sure that they take everything that they need for their
first class to breakfast with them.
Cleaning the Cabin
The purpose of cabin clean-up is to help campers keep their belongings separate, organized and
together; keep the cabin hygienic and make packing up on Friday easier. It is important for
EVERYONE to pitch in and do their part and help each other using teamwork.
TOILETS Flushed, scrubbed, paper neatly stacked on the back
FLOOR Tile floors swept and mopped; carpet swept or picked up
SHOWERS Turn off handles as tightly as possible, Pull shower curtains back and make sure
no toiletries are left behind
SINKS Check for hair or toothpaste. Nothing may be left out.
BEDS Made as neatly as possible. They may have their pillow and stuffed animal on the
bed, but nothing else. Shoes may not be left of floor or under bed.
SURFACES Nothing may be left out. All toiletries, towels, hairdryers, etc. must be packed
into suitcases.
SUITCASES All clothes put away and cases zipped. May be under the bed, at the foot of the
bed, or neatly stacked in the closet area. Blankets, if not used, must be neatly
stacked in the closet, or folded across the bottom of the bed.
TRASH All trash cans must be emptied and turned over to show there is nothing inside.
They must be relined with a clean bag. All trash must be put in the bins located
at the street between every two cabins. Pick up trash in your area on the way to
breakfast.
WET ITEMS Towels and suits may be hung out on the lines shared between cabins. Wet
towels may be hung neatly over the end of the beds, if necessary.
PORCH Sweep porch and doormat.
Thursday Night
On Thursday Night, campers will be asked to do the following to make Friday morning much
easier.
Pack everything that is not necessary for Friday morning.
Pull laundry from clothesline.
Anything unclaimed will be put on the 4-H office porch for parents to claim. This
includes your underwear so please claim your items!
EVERYTHING MUST FIT BACK INTO YOUR SUITCASE, NO TRASH BAGS OUTSIDE OF THE
SUITCASE.
8
Friday July 9
Campers will dress, pack and load luggage before cleaning the cabin. Every bed should have a
Rock Eagle pillow and blanket left on it. Leaders will help pack medications into child’s suitcase
if there is time, otherwise, medications will be available for parents to pick up at the 4-H office
upon our arrival. Once the counselor officially checks the cabin, everyone walks to breakfast.
After breakfast, will be time to say good-byes before the awarding of the tribal shield.
Our approximate arrival time back to the 4-H office is 12:45pm! PLEASE BE ON TIME TO PICK
UP YOUR CHILD! And don’t forget to look over our lost and found and pick up medications if
they were not packed by the leader. (Listen for the announcement as we exit the bus).
Contact Information
We must have CORRECT EMERGENCY CONTACT PHONE NUMBERS!! If your phone number
changes, please notify us prior to camp.
4-H’ers are not allowed to call home except in emergency situations. There are no telephones
available at the camp to call home. Please do NOT send a cell phone with campers, if they are
found, they will be taken up by the leader and given to you upon arriving at home.
Walker County 4-H Leaders will be in constant contact with the local 4-H office at all times, if
you want to check on your child, you must call (706) 638-2548 during office hours, or leave a
message after hours.
REMEMBER THAT NO NEWS IS GOOD NEWS!
ALSO, campers have a much better time when they know everything is fine at home.
Family and friends may send mail to campers the week BEFORE camp. Address as:
Camper’s Name, Walker County
Week July 6-9
Rock Eagle 4-H Center
350 Rock Eagle Road NW
Eatonton, GA 31024
You may also email the campers. You can go to www.georgia4h.org/camp/ and find a link called
“Camper E-mail.” This will open a form that you can use. Please, PLEASE only distribute the
password to parents or other guardians. (Password: clover)
I will post on our Walker County 4-H Facebook page when we have arrive to camp safely, when
we are leaving camp on Friday and when we are close to home on Friday. There may also be a
few photos, but that is not guaranteed as we are busy having fun with your children, so please
do not ask for specifics on these posts. https://www.facebook.com/walkercounty4H/
9
What to Bring
Campers can bring ONE suitcase or soft side luggage with a lock and key. However if the key is
lost, it may take a day to get bolt cutters to get into the suit case. Transportation for luggage is
limited and 4-H’ers must carry their own luggage to the cabins, so pack light!!!
*All Items should be marked with the Child’s Name on the Inside of Clothing and Towels*
Linens for a Twin/Bunk Bed OR a Sleeping Bag (sleeping bag is best)
Pillowcase (Pillows provided, but you may bring a pillow if you would like)
Towels (shower & beach towels) & washcloths (thinner is better for drying and packing)
Daily change of underclothing/clothing (shorts, t-shirts, etc.)
Pack clothes that can get dirty. Old clothes for wet games.
Comfortable walking shoes. Bring at least 2 pairs—one that can get wet & muddy
Swimsuit, both modest and appropriate (girls: one-piece ONLY is best)
(I suggest two suits so one can dry while you wear the other)
Rain gear (preferably a small rain poncho)
Plastic Garbage Bag for Wet Clothes
Gallon size zip-top bag or shower caddy with Toiletries (shampoo, soap,
toothbrush, toothpaste, hair brush, etc.)
Insect Repellant & Waterproof Sunscreen Lotion (30 SPF or stronger)
Inexpensive, waterproof watch
Extra Money for souvenirs and snacks (not over $20 please)
Face masks (6 if possible) to use as needed, campers will need to keep up with these
Optional Items
Sport Sandals (the kind with a heel strap like Tevas or Chacos)
Disposable camera(s) LABELED WITH CAMPER’S FULL NAME AND COUNTY!!!
(I suggest 2-3 as the cameras at Rock Eagle are expensive & campers like taking photos)
Pen, Paper, Stamps (although 4-H’ers will be home before letters will be)
Portable Water Bottle (water and fountains are available at each class)
Shower Shoes
Day Pack (fanny pack) or thin drawstring backpack (I suggest netted for ventilation)
10Tuesday July 6
11:45am Meet at Walker County Extension Office & leave for camp!
4.00 - 5.05 Milk Cottage
5.15-6:10 Dinner 1
6.15-7:10 Dinner 2
7.15 - 8.35 Activity 1
8.45 - 9.15 Tribal Meetings
9.30-9.50 Cottage Meeting - Milk
10.30 Lights Out**
Wednesday through Thursday
July 7 July 8
7.15-8.10 Breakfast 1 7.15-8.10 Breakfast 1
8.15-9.10 Breakfast 2 8.15-9.10 Breakfast 2
9.15-10.35 Activity 2 9.15-10.35 Activity 6
10.45-12.05 Activity 3 10.45-12.05 Activity 7
12.15-1.10 Lunch 1 12.15-1.10 Lunch 1
1.15-2.10 Lunch 2 1.15-2.10 Lunch 2
2.15-3.35 Activity 4 2.15-3.35 Activity 8
3.45-5.05 Activity 5 3.45-5.05 Activity 9
5.15-6.10 Dinner 1 5.15-6.10 Dinner 1
6.15-7.10 Dinner 2 6.15-7.10 Dinner 2
7.15-7.45 Tribal Meeting 7.15-8.15 Tribal Meeting
8.00-9.00 Variety Show 8.30-9.45 Rock Eagle Pageant
9.15-9.35 Milk 10.00-10.20 Milk
10.15 Lights Out** 11.00 Lights Out**
Friday July 9
7:30 Breakfast 1
8:30 Breakfast 2
9:30 Awarding of the Tribal Shield
9.45 Homeward Bound
12:45 Tentative approximate arrival time at Walker County Extension office
PLEASE be on time to pick up your child!
Do not forget to pick up their medicine bags before departing.
Hope you are ready for a great week of camp!
11Map to Rock Eagle
(We hope you never need this, but just in case)
The travel time to Rock Eagle from LaFayette is
approximately three hours.
Take I-75 South to I-20 East (toward Augusta).
Travel approximately 57 miles on I-20.
Exit on the US 129/441 exit number 114.
Turn right off the exit ramp.
Travel about 10 miles and the entrance to Rock Eagle will
be on the right.
For more information, go to: www.rockeagle4h.org
12Rock Eagle Campus Map
13Other Information and Photos
Walker County Extension
Wade Hutcheson
County Extension Coordinator Rebecca Hamilton
County EFNEP Program Assistant
Casey Hobbs
County 4-H Extension Agent
Jennifer Meeks
Kellie Wilson County Extension Secretary
County 4-H Program Assistant
Mailing Address
Office Location P.O. Box 827
102 East Napier Street LaFayette, GA 30728
LaFayette, GA
Phone: 706-638-2548
Office Hours Fax: 706-639-4976
Monday-Friday E-mail: walker.extension@uga.edu
8 a.m.—5 p.m. Noon-1 p.m. closed for lunch
www.ugaextension.com/walker
14CLOVERLEAF 4-H
SUMMER CAMP
MEDICAL & CONDUCT
FORMS
THESE FORMS ARE DUE BACK TO THE
4-H OFFICE
NO LATER THAN
Thursday July 1, 2021
Walker County 4-H
PO Box 827 | 102 E. Napier Street
LaFayette, GA 30728
(706) 638-2548Georgia 4-H Medical Information & Release Form
This form should be completed prior to each 4-H event.
July 6-9, 2021
Cloverleaf 4-H Summer Camp Rock Eagle Date(s) of EVENT:_____________________________________________________
EVENT: __________________________________________________________
4-H’ers Information
Name County Walker
Address
Date of Birth Grade Gender Preferred Phone _________________________
Parent/Guardian Information
Name: Preferred Phone: Alt. Phone:
Email Address:______________________________________________________ Text:________________________________________________________________
Name: Preferred Phone: Alt. Phone:
Please list the names of two adults other than parent/guardian who may be contacted in case of emergency.
Name: Preferred Phone: Alt. Phone:
Name: Preferred Phone: Alt. Phone:
Medical Information
The following information is requested in case of accident or illness to better treat your child.
The information is optional and not required for participation.
Name of Physician: Phone:
Date of Last Physical Examination: Drug Allergies:
Other Allergies:
Describe any recent illness or injury:
Describe any pre-existing conditions:
Describe any other circumstances that would help leaders or medical professionals in working with the 4-H’er:
PARENT/GUARDIAN AGREEMENT:
I understand that should a health problem arise, I will be notified but that if I cannot be reached by telephone, such medical treatment, including surgery, as deemed necessary by
competent medical personnel could be rendered; that such necessary information may be released for insurance purposes. Furthermore, I am aware that participation in 4-H
programming includes risk including, but not limited to, transportation to/from events, sports and recreational games, ropes courses, water activities, hiking, as well as risks that
are not foreseeable. Risks also include exposure to contagious diseases and communicable illnesses, including but not limited to COVID-19. For the sole consideration of the
Cooperative Extension Service’s arranging for participation in 4-H programming, I hereby release and forever discharge TheUniversity of Georgia, the Board of Regents of the
University System of Georgia, their members individually, and their officers, agents and employees from any and all claims,demands, rights and causes of action of whatever kind
that I may have, either on my own behalf or in my capacity as a legal representative of my child, arising from or in any wayconnected with my child’s participation in 4-H. I further
covenant and agree that for the consideration stated above I will not sue the Institution, the Board of Regents of theUniversity System of Georgia, it’s members individually, its
officers, agents or employees for any claim for damages arising or growing out of my child’s participating in the program.I understand that the acceptance of this Release, Waiver of
Liability, and Convent not to sue the Board of Regents of the University System of Georgia shall not constitute a waiver, inwhole or part, of sovereign immunity by said Board, its
members, officers, agents, and employees. I certify that my child is participating in 4-H with my knowledge and consent. Ihave read and understand all of the above policies. I
hereby grant permission for my child’s images, likeness, and voice to be recorded in any media during this program and to beused by the University of Georgia and Georgia 4-H on
behalf of the Board of Regents of the University System of Georgia in any publications, media, or technology now known of orhereby developed in the future for any lawful purpose
whatsoever without further permission from me. I understand I will not be compensated further for use of these recordings.
_________________________________ _____________
Parent/Guardian Signature Date
5/2021 PLEASE COMPLETE BOTH SIDESOver the Counter & Prescription Medication Summary
4-H’ers Name County Walker
Parent/guardian should list any over-the-counter medication that may be given to the 4-H’er in case of illness. In
addition, list any/all medication routinely taken by the 4-H’er including prescription and over the counter
medications.
Check Yes or No to indicate if you allow your child to receive the following medications while participating
in 4-H programming.
1. Administration of Acetaminophen (Tylenol ) or Ibuprofen (Motrin or Advil ) at an age appropriate or
weight appropriate dose for discomfort, pain, or fever
Yes No *** Parent/Guardian will be contacted if student’s fever is 100° F or higher.
2. Antacid liquid or Antacid tablets for indigestion/minor stomach discomforts and at an age appropriate dose
Yes No
3. Diphenhydramine (Benadryl) for symptoms of allergic reactions, insect stings, or rashes at an appropriate
dose
Yes No
4. Sore throat relief spray for sore throat
Yes No
5. Cough Drops for coughing
Yes No
6. Itch and rash relief cream/ointment for minor skin irritations
Yes No
7. Lubricating eye drops for eye irritations
Yes No
8. Oral pain relief gel for tooth/mouth discomfort
Yes No
9. Triple antibiotic ointment for minor skin abrasions/wounds
Yes No
Please list any prescription, over-the-counter, or homeopathic medications your child is currently taking.
This information is necessary if your child is to be treated by a medical professional. Examples: Claritin,
vitamins, etc. If the following medication should be administered during this event, complete the Georgia 4-H
Medicine Form. Any medications brought to a program must be in its original container, unexpired, and clearly
labeled with the 4-H’ers name. Youth may not share any medication with others.
All medications should be turned in to program/activity leaders at the program start and should accompany a
Georgia 4-H Medicine Form. Any exceptions to this (such as an inhaler for asthma or an epi-pen for allergic
reactions) must be verified with a 4-H staff member prior to the event.
Medication Condition being treated for
I am the parent/guardian of ________________________________________and give permission for the medications listed to be
administered as directed. By signing below, I am agreeing the information is currently correct. I agree to notify 4-H
immediately in writing should any of this information change. I also understand that I will be notified if my child
distributes or shares any prescription, over-the-counter, or homeopathic medication, or if my child is found to be
in possession of any medications not listed on this form.
________________________________ ____________________
Parent/Guardian Signature Date
5/2021 PLEASE COMPLETE BOTH SIDESGeorgia 4-H Medicine Form This form
should accompany
Name of 4-H’er: any medication
to be given at an
County: Walker 7/6-9/2021
_____________________________ Date(s): ____________________ event.
Activity where medication may be administered:
Cloverleaf 4-H Summer Camp, Rock Eagle
________________________________________________________________________________
Please list any medication(s) your child will be taking while at the above event.
(Attach additional page if necessary).
Name of Medication: ____________________________________________________________________________________________________________
Illness/condition medication is being taken for: _____________________________________________________________________________
Date(s) medication is to be given: ___________________________________________________ Time: ____________________________
Describe what the medication looks like? ____________________________________________________________________________________
Describe dosage and special instructions: ____________________________________________________________________________________
My child will be taking the above noted prescription or over-the-counter medication that I am providing while they
are involved in the above activity. I understand that any medications brought to a program must be in its original
container, unexpired, and clearly labeled with the 4-H’er’s name.
Parent/Guardian Signature: ______________________________________ Date: _________________
To be completed by administering leader
Date Time Leader initials 4-H’er initials Notes
7/25/2019 ADDITIONAL PAGES AS NECESSARYGeorgia 4-H Medicine Form – Additional Page – Name of 4-H’er: ____________________________________
Name of Medication: ____________________________________________________________________________________________________________
Illness/condition medication is being taken for: _____________________________________________________________________________
Date(s) medication is to be given: __________________________________________________ Time: ____________________________
Describe what the medication looks like? ____________________________________________________________________________________
Describe dosage and special instructions: ____________________________________________________________________________________
My child will be taking the above noted prescription or over-the-counter medication that I am providing while they
are involved in the above activity. I understand that any medications brought to a program must be in its original
container, unexpired, and clearly labeled with the 4-H’er’s name.
Parent/Guardian Signature: ________________________________________________________________________________________
To be completed by administering leader
Date Time Leaders initials 4-H’ers initials Notes
Name of Medication: ____________________________________________________________________________________________________________
Illness/condition medication is being taken for: _____________________________________________________________________________
Date(s) medication is to be given: __________________________________________________ Time: ____________________________
Describe what the medication looks like? ____________________________________________________________________________________
Describe dosage and special instructions: ____________________________________________________________________________________
My child will be taking the above noted prescription or over-the-counter medication that I am providing while they
are involved in the above activity. I understand that any medications brought to a program must be in its original
container, unexpired, and clearly labeled with the 4-H’er’s name.
Parent/Guardian Signature: _________________________________________________________________________________
To be completed by administering leader
Date Time Leader initials 4-H’er initials Notes
7/25/2019 ADDITIONAL PAGES AS NECESSARY4-H’er Name: _______________________________ County: ____________________
Walker NW
District: ______
COVID-19 Diagnostic Testing Permission
Permission to participate in the testing strategy is required for participation
in this 4-H activity: _______________________________.
Cloverleaf 4-H Summer Camp, Rock Eagle, July 6-9, 2021
Georgia 4-H is committed to a safe and healthy environment. There are many safety
precautions in place to help prevent the spread of COVID-19 (www.georgia4h.org/camp/
COVIDsafety). One of those precautions is the diagnostic testing strategy which is designed
with the health and safety of 4-H’ers and their cohorts of fellow 4-H’ers and adult/teen leaders.
General Outline
At the 4-H activity, if an individual exhibits any symptoms of illnesses they will report to the
Health Cottage to be seen by the nurse.
Upon examination, if the symptoms are determined to be COVID symptoms, the nurse will
administer an on-site COVID-19 antigen (rapid) test at the Health Cottage.
While awaiting results, the individual will need to stay isolated but will still be under the
supervision of an adult leader.
As soon as antigen results are available, next steps depend on the outcome as follows:
− Positive Result – individual who tested positive as well as their cohort and/or anyone else
who had close contact (as defined by CDC) will isolate while pick-up plans are implemented.
Because of confidentiality requirements, the positive individual shall not be named or
identified.
− Negative Result – the nurse will help determine next steps based on medical expertise.
Typically, if an individual with COVID-like symptoms has a negative antigen test result, a
follow up PCR test will be recommended and can be administered at a local urgent care
facility during their normal operating hours. The symptomatic 4-H’er may still need to go
home to recover and/or reduce transmission of any illness upon recommendation of the
nurse.
*************************************************************************************************************
I am the parent/guardian of ________________________________________and give
permission for the administration of COVID-19 test(s) if determined the best course of action by
the on-site medical professional. I also understand that I will receive a courtesy call about test
administration, but that my consent here allows Georgia 4-H to proceed as described above. I
further understand that I am ultimately responsible for providing transportation home for my
4-H’er in the event of a positive COVID-19 test or exposure. I acknowledge that I have read,
understand, and have signed the Georgia 4-H Medical Information & Release Form and
understand that the Parent/Guardian Agreement I have signed applies to this Covid-19 Diagnostic
Testing Permission Form and is incorporated as if fully set forth herein.
_______________________________________ _____________________________
Parent Guardian Printed Name Contact Phone Number
_____________________________ _____________________________
Parent Guardian Signature Date
May 17, 2021 VersionYou can also read
