2025 SCC 4-H Summer Camp Chaperone Application

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Region 7, 4-H Camp

Chaperone Application

2025

June 22 – 27, 2025

Camp Daybreak

in Felton, California

Chaperone Eligibility

To be a Camp Chaperone, you must:

Be 25 years of age by December 31, 2024
Complete the enrollment process required to be a certified 4-H volunteer. If you are not currently enrolled as a 4-H volunteer and active in ZSuite, you must complete all of the NEW volunteer steps linked here.

Camp Chaperone Application Process

Complete the chaperone Application and be selected.
Complete the UC CA State 4-H Overnight Chaperone training (Bi-annually)
Complete the online FirstAidWeb Inc Online Training for First Aid and CPR. (Bi-annually)
Send confirmation of training to zmahmood@ucanr.edu

All Adult Volunteers must adhere to the Adult Volunteer Code of Conduct.

✻ = Required

2025 Summer 4-H Camp

ADULT Chaperone Application

Please use this application to indicate your interest in participating

as an adult chaperone for the 2025 4-H Summer Camp.

Applications will be held open until all chaperone positions are filled,

bu no later than May 15, 2025

What adult position are you applying for? ✻

Chaperone June 22 to June 27 Chaperone June 22- June 26 Chaperone 2 nights Adult Staff June 22- June 27 Day Chaperone Only Clover Day Chaperone only

Last Name: ✻

First Name: ✻

Cell Phone number:

Please use format 000-000-0000 ✻

Email address: ✻

4-H Club: ✻

Gender:

✻

Were you at least 25 years old on December 31, 2024?

Overnight chaperones in Santa Clara County are required to be 25 years or older. ✻

Yes No

What is your T-shirt size? ✻

Adult Small Adult Medium Adult Large Adult Extra Large 2X 3X

Do you have food allergies or preferences that you would like the camp kitchen to know about? ✻

Egg Allergy Nut Allergy Dairy Allergy Gluten Free Celiac Halal Vegan Vegetarian Other

Is there additional information that you would like the camp kitchen to know about?

Do you have any physical or medical needs you would like to share with the camp heath officer? ✻

Please describe any other overnight chaperone or youth leadership experiences you have had for 4-H or other youth programs/organizations.

For example: Leadership Overnight Chaperone, State Leadership Overnight Chaperone ✻

What if any are your current adult leadership roles in the 4-H program? (e.g. project leader, club leader, event coordinator, etc.). If applicable, list leadership roles in other organizations. Please list all roles you currently hold. ✻

Do you have a current CPR/First aid certification? (this may be attained once you are appointed to the position) ✻

Yes No

Have you ever taken the 4-H Food Safety First course? ✻

Yes No

Have you ever attended the California State 4-H Camping Conference? ✻

Yes No

Describe your experience in teaching and working in partnership with youth ages 9-18. ✻

What strategies will you use to create a welcoming camp for diverse youth and adult volunteers? ✻

ANR NONDISCRIMINATION AND AFFIRMATIVE ACTION POLICY STATEMENT FOR UNIVERSITY OF CALIFORNIA

It is the policy of the University of California (UC) and the UC Division of Agriculture & Natural Resources not to engage in discrimination against or harassment of any person in any of its programs or activities (Complete nondiscrimination policy statement can be found at http://ucanr.edu/sites/anrstaff/files/215244.pdf)Inquiries regarding ANR’s nondiscrimination policies may be directed to UCANR, Affirmative Action Compliance & Title IX Officer, University of California, Agriculture and Natural Resources, 2801 Second Street, Davis, CA 95618, (530) 750-1343.

Survey Verification✻

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QBRPQA

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