Having well trained camp counselors is vital for a safe and fun camp. The mandatory training is for everyone.

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1 TO: FROM: SUBJECT: Preston County 4-H Camp Volunteers David Hartley, 4-H Agent Preston County 4-H Camp Counselor s Packet Our 4-H'ers would not be able to experience 4-H Camp without the help of all our wonderful volunteers. What does being a "4-H Camp Counselor" mean? The range of counselor responsibility could be from volunteering for a couple hours, to being a counselor who is fortunate enough (and/or willing) to stay day and night for 5 days. If you can't stay five nights but can manage 2 or 3 nights, that would help us a great deal. The camp packet includes: o Position Description o Counselor Application - Return by April 22, 2016 (Please be very specific as to what times you will be available, at which camp, and for what duties.) o Health Statement for Counselors o A new Code of Conduct for 2016 Counselor applications will be reviewed and assignments will be made through the Extension Office. If you have something in particular you wish to assist with and it is not listed on the application, please make a note on the application. MANDATORY TRAINING FOR COUNSELORS: Having well trained camp counselors is vital for a safe and fun camp. The mandatory training is for everyone. We will have a Staff Training starting on Saturday June 4, 2016 at 4-H Camp. We will start at 5:00pm with dinner and conclude at 8:30pm. Makeup Training will be on June 13, 2016 at WVU Preston County Extension Office, this training will be webcast. Each year you will need to complete the WVU Children on Campus Training. The link for the handout is Once you review the handout take the quiz and send a copy of the centificate to the extension office. Link for the is: If you can't meet the training requirements, you may make arrangements with the Extension Office for other options. If you have any questions, please feel free to contact the Extension Office at

2 H Camp Counselor Application Please print or type Name and Contact Information Last Name First Name Middle Initial Preferred Name as will appear on name tag Mailing Address Home Phone Cell Phone General Information Gender (circle one) M F Adult T-shirt size (circle one) S M L XL XXL 3XL Special Accommodations and/or Dietary Needs: Please check one: I am a current volunteer in good standing. _I am not a current volunteer and will need to complete a volunteer application. Current Position(s): paid and/or volunteer Dates Employer/Supervisor Address & Phone Nature of Work Camp Experience (last three years and/or most recent) Dates Camp & Director Location Camper or Staff/ role

3 What contributions do you believe you would make to camp? What specific efforts have you undertaken that demonstrate your ability to plan, conduct, and teach programs at 4-H camp? Please explain your experience working with youth from different backgrounds, counties, or organizations that demonstrates your ability to work with youth that have previously been unknown to you? Please list specific training you have had regarding camping in the last 3 years? Certifications and Camp Support Skills: Check all that apply Health/Safety CPR Physician Current driver s license WSI First Aid Wilderness First Aid Food Handler s Permit Lifeguard EMT Nurse Practitioner Shooting sports (check all) LPN RN BSN (circle one) Physicians Assistant Air Rifle Air Pistol Shotgun Paramedic Other (list) Archery Black Powder Wildlife Management Which of the following camp activities are you willing to help with? Volunteers are needed that are willing to do multiple tasks. Please check all that apply. Cottage Counselor Opening Registration Meditations Alternate afternoon activities Cottage Check Sports Supervision Cottage Clean-Up (Friday Swimming Supervision Party Helper afternoon) Cottage Host (Sunday) Council Fire Building Camp Canteen Assistant Class Teacher Evening Snacks Kitchen help for meals Banquet Flags Duty Bath House Duty

4 Are you able to teach a camp class? Yes No Class Name: Availability Can you be in camp full time for Older Camp (July 3-8) Younger Camp ( July 17-22) Yes No If No, are you able to stay overnight at camp, but not be at camp full time? Yes No If you are able to stay overnight, you will be able to arrive at depart at _in the morning. in the evening and need to If you are not available full time or nights, please indicate times that Morning Afternoon you would be available during these parts of the day. Evening Ex: Morning Monday through Friday, 10:00 am to Noon. Non- Programs and activities offered by the West Virginia University Extension Service are Discrimination available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political beliefs, sexual orientation, national origin, and marital or family status. If selected as a volunteer, do you agree to abide by and uphold these policies? Yes No Criminal Record Explain: Have you ever been convicted of a crime, other than a minor traffic offense? If yes, please describe. (Note: a prior conviction is not an automatic bar to volunteering. The type of conviction and when it occurred will be evaluated by the camp before any decision is made.) Yes No Tobacco Free Policies According to West Virginia University Board of Governors Policy #57, all WVU property (including Jackson s Mill) is tobacco free, which includes all forms of tobacco products. 4-H also prohibits the use of tobacco at all of its events and programs. I agree that, if selected as a camp volunteer, I will abide by these policies prohibiting the use of tobacco products. YES NO Title IX Policy Title IX of the Education Amendments of 1972 (Title IX) is a Federal law which prohibits discrimination on the basis of sex in any educational program or activity receiving federal financial assistance. Since Cooperative Extension 4-H Programs receive Federal financial assistance for education programs, they must adhere to United States Department of Agriculture regulations prohibiting discrimination on the basis of sex. West Virginia University Board of Governors Policy #44 prohibits discrimination, harassment, sexual misconduct, domestic misconduct, stalking, and retaliation that occurs on WVU property (including Jackson s Mill) or during a WVU sponsored activity (which includes any 4-H event). As a part of this policy, all persons are expected to engage in conduct that meets professional standards, take appropriate action to prevent prohibited conduct, and avoid behavior that a reasonable person would construe as prohibited conduct. I agree that, if selected as a camp volunteer, I will abide by all Title IX policies and all policies and regulations related to the prohibition of discrimination, harassment, sexual misconduct, domestic misconduct, stalking, and retaliation. I also understand that I may be required, at any time, to take part in training related to these policies in order to continue as a volunteer. YES NO

5 Children on Campus Policy West Virginia University Board of Governors Policy #49 prescribes the rules and regulations to protect any person under the age of 18 attending a WVU program (including any 4-H program or event) on WVU property (including Jackson s Mill). This policy mirrors West Virginia Code 49-6A-1 to -11 by reiterating that all youth camp counselors and volunteers are mandated to report any suspected child abuse or neglect, including physical abuse or neglect, to the West Virginia Department of Health & Human Resources Child Protective Services (CPS), the WVU Title IX Coordinator, and local police. The policy also mandates training for all employees and volunteers who will have direct contact with children. I understand that the information that I have provided may be verified by contacting persons or organizations named in this application and I hereby release from liability any person or organization that provides information concerning me to the representatives of West Virginia University Extension 4-H Youth Development. In signing this application, I affirm that the information I have given herein is true and correct. If selected as a volunteer, I understand I serve at the request of the West Virginia University Extension Service. That request can be withdrawn for any reason or no reason at any time. I will be required to undergo a background check. A criminal record will not necessarily bar me as a volunteer, but will be considered as it relates to the specifics of the volunteer position for which I have applied. I also affirm that I will disclose to West Virginia University Extension Service if my status changes after the background check. I will immediately disclose any and all pending charges or criminal convictions. I also understand that I will be required to undergo mandatory training prior to and during my service as a volunteer. Signature Date: For Office Use Only Accepted: Declined: Date: Reason: Programs and activities offered by the West Virginia University Extension Service are available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political beliefs, sexual orientation, national origin, and marital or family status. The WVU Board of Governors is the governing body of WVU. The Higher Education Policy Commission in West Virginia is responsible for developing, establishing, and overseeing the implementation of public policy agenda for the state s four-year colleges and universities. Please return complete application by mail, fax, or to: WVU Extension Service 115 West Court Street Kingwood, WV RETURN NO LATER THAN May 1, 2015 I am unable to apply this year, but keep my name on the list Updated Contact Information (if any changes): Name: Address: Phone:

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7 West Virginia 4-H Volunteer Code of Conduct This Code of Conduct is a contractual agreement accepted by volunteers who commit to the 4-H program. The Code of Conduct shall guide their behavior during their involvement in West Virginia 4-H. Just as it is a privilege for the West Virginia University Extension Service to work with individuals who volunteer their time and energies to West Virginia 4-H, a volunteer s involvement in West Virginia 4-H is a privilege and a responsibility, not a right. The West Virginia 4-H program provides quality, educational programs accessible to all West Virginia youths. The primary purpose of this Code of Conduct is to ensure the safety and well-being of all 4-H participants (members, their parents and families, professionals, and volunteers). West Virginia 4-H volunteers are expected to function within the guidelines of the West Virginia Extension Service and the West Virginia 4-H program. West Virginia 4-H volunteers shall be individuals of personal integrity. West Virginia 4-H volunteers will: Adhere to all policies outline in Title 49, Children on Campus. Uphold volunteerism as an effective way to meet the needs of youths and adults. Uphold an individual s right to dignity, self-development, and self-direction. Accept supervision and support from professional Extension staff while involved in the program. Accept the responsibility to represent their individual county 4-H program and the West Virginia 4- H program with dignity and pride by being positive mentors for the youths with whom they work. Conduct themselves in a courteous and respectful manner, exhibit good sportsmanship and provide positive role models for all youths. Respect, adhere to, and enforce the rules, policies, and guidelines established by their individual county 4-H program, the West Virginia 4-H program, and the West Virginia University Extension Service. Not abuse any 4-H participant by physical or verbal means and will report such abuse, if observed, as outlined in the West Virginia University Extension Service Youth Protection Policy. Not commit a felonious criminal act. Comply with equal opportunity and anti-discrimination laws. Discharge duties in a responsible and timely manner. Promote a welcoming environment by fostering a climate based on social justice. Report immediately any threats to the volunteer s emotional or physical well-being to the county 4-H professional. Accept the responsibility to promote and support 4-H in order to develop an effective county, state, and national program. Handle animals and operate machinery, vehicles, and other equipment in a responsible manner. Social media and technology including cell phones will be used in an appropriate and respectful manner in accordance with Title 49 Children on Campus. Abstain from harassment or bullying of another participant, volunteer or staff member (either in person or face to face or through social media or other communication venues). I have read and understand the Code of Conduct outlined above. I understand and agree that any action on my part that contradicts any portion of this Code of Conduct is grounds for the suspension and/or termination of my volunteer status with the West Virginia 4-H program. Signature of 4-H Volunteer Signature of Extension Professional Date Date

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