event information/registration form - 4

Washington 4-H Shooting Sports 2015 State 4-H Championship
Held at Upper Nisqually Sportsman Club 39919 129th Ave Eatonville 98328
May 15 – 17, 2015
Hello everyone and welcome to your first step to entering the Washington State Championship!
As you may be aware, this will be the 5th year that 4-H at Upper Nisqually has had the privilege to host this event.
While there is a great deal of preparation, long hours, hard work and hundreds of emails…we are still really excited!!!
The awesome It’s All Good Coffee truck will be back again this year as well as Cruizer Café offering breakfast and
lunch options for everyone.
Last year we had nearly 160 youth participate in the event! This is a record and triple the number of shooters from the
1st year it was held. I want to make sure that everyone understands that normally the 4-H State Championship is held
only for Senior shooters. It is how they qualify to attend the National Championship. That said: Washington 4-H
shooting sports is still in its infancy compared to some states therefore the state shooting sports committee has decided
not to discourage any junior and/or intermediate (JR/INT) member participation. Provided they know the range
commands and are safe. We will run modification for the JR/INT members as needed. To accommodate this, Sunday
will be a full day. Upon registration deadline we will issue a schedule. At this time plan for all day Saturday & Sunday.
Participants shoot on both days. Please don’t ask about scheduling changes so folks travelling long distances can be
done early. It does not work for the schedule. Bring lawn chairs for awards and dress for the weather 
It was brought to our attention that we may have had some possible dishonesty happening in the archery scorecard area.
Please consider the consequences vs. the rewards and the lessons that our youth are learning through actions such as
these. Remember to read your rules so you are following guidelines for correct protest/dispute needs during the event.
Scoring is taken directly from the National contest. We will offer a scoring overview on Saturday morning At 6:30 AM
sharp for interested parents, leaders and members! Details go to page 7 of the link here
http://4h.unl.edu/documents/466759/4358054/2015+General+Rules+-+Final.pdf/e8ba7976-5068-4fdc-915a-a1246ff75
b23
If you would be able to lend a hand on Sunday for the tear down/clean up of the facility it would be greatly appreciated.
Everyone is tired and wants to get home however we could use some additional hands please.
There are some things that you can do to help the event run as smoothly as possible.
1. Fill out the registration paperwork legibly and completely otherwise it will be discarded.
2. Send ALL completed paperwork** TOGETHER with payment by deadline.
3. Upon arrival Friday proceed to registration which will be open at 2pm, not before.
4. Have equipment check done upon arrival. Schedule and location posted at registration.
5. Be at your daily events prepared, proficient and early.
6. If you are willing to help score the firearm events please advise upon arrival at registration.
**Your completed paperwork consists of legible registration, waiver and health release form.
We are limited on sponsorship this year. Please bring an appropriate item to donate as a prize. You may turn it in at
registration. We will again draw names of the participants and award prizes. If you would like to donate to the event in
general. The registration office has tax deductible receipts.
For questions regarding the event please do not call the Sportsman Club, email Tammy only. The club has no knowledge
of our event specifics.
Washington 4-H Shooting Sports 2015 State 4-H Championship
Held at Upper Nisqually Sportsman Club 39919 129th Ave Eatonville 98328
May 15 – 17, 2015
2015 REGISTRATION FORM
Registration & Equipment check open 2pm Friday closed at 8pm.
Registration & Equipment check open 6am Saturday closed 7:30am. Arrival Friday suggested.
Opening Ceremony: 8:05am Saturday
Target Assignments/Safety Meetings: 8:30am
Name:_________________________________________________________
Phone:_____________________________
Club Name _______________________________________________________ County____________________________
Email address:_________________________________________________________________________________________
Age:________ DOB: ___________ Homeschool: Y or N Grade in School__________ Age on Jan 1 2015: _________
Registration Deadline: Fees and ALL paperwork to arrive no later than April 30th, 2015.
Registration by mail ONLY
Please do NOT email any paperwork.
Registration Fee - $30
Shotgun Registration Fee - $65.00
Shotgun does not pay $30 registration fee, just applicable shotgun registration fee
Make checks payable to: 4-H at Upper Nisqually
Mailing address: WA 4-H Championship c/o Tammy Klein,
9905 395th ST E. Eatonville, WA 98328
Registration questions: Tammy Klein : [email protected]
KEEP UPDATED: https://www.facebook.com/pages/4-H-at-Upper-Nisqually/247499285274903
Optional: 2015 State Tee shirt pre-order only $15.00 per shirt. Anyone can support 4-H by purchasing a shirt or shirts.
Adult Sizes Qty:
S:
M:
L:
XL:
XXL:
XXXL:
Camo tee shirt with WASS logo on back
Please Circle Discipline/ Division: (One per participant)
AGE DIVISION: Jr.
.22 Rifle
Shotgun
.22 Pistol
Air Rifle
Air Pistol
Hunting
Archery: Compound or Recurve
Int.
Sr.
Muzzleloading
By signing you agree that you have read and understand the rules and synopsis for the event your registering in.
Failure to be proficient in all events, follow safety procedures, dress code or code of conduct will result in removal from the event.
This is not a time for us to train you, you need to be proficient in all aspects prior to arrival.
Read synopsis before registering, our timeline does not allow for training delays.
Participant signature _____________________________________________
Date________________________________
WSU 4-H EXTENSION STAFF SIGNATURE (not club leader or instructor)
WSU Sign Name:___________________________________________ WSU Print Name:______________________________
Fees breakdown:
Participant entry fee this page: _________ Tee shirt pre-order fees :_________
Camping fees $10/night :_________
Payment info: Check # :__________ Amount: __________
REGISTRATION USE ONLY DO NOT WRITE HERE PLEASE
$ Collected________________________________
Attention needed ___________________________
REGISTRATION COMPLETE
WSU Extension 4-H Shooting Sports Waiver Form
Event/Activity: Washington State 4-H Shooting Sports Championship—Upper Nisqually Sportsman Club
Participant Name(s): (please print legibly):
___________________________________________________________________________________________________________
Supervision of this program is under the direction of the WSU Extension. All participants are responsible for
their conduct to WSU Extension personnel, to 4-H Leaders, and to other persons supervising this program.
I, undersigned parent or guardian of the participant name below recognize the dangers present in the shooting
sports disciplines such as archer, rifle, shotgun, muzzle loader, pistol, hunting and there activities.
(Circle disciplines that apply) I believe the Washington State 4-H Shooting Sports Leaders and their assistants
are dependable and reliable and will provide safe experiences. I understand that during the course of shooting
sports trainings, and events that it may be necessary to position my child to demonstrate such topics as proper
stance or correct shooting positions.
I hereby grant permission for my child to participate in the shooting sports program, or event. I knowingly and
freely assume all such risks, for example: bodily injuries well as loss or damage to property. I understand as the
parent/guardian signing this form that I will be held financially responsible for any expenses above and beyond
what the 4-H insurance will pay. I assume all risks involved while using equipment supplied in this program. Participants are responsible for their own equipment.
I authorize the use of photographs or video of my child, family, and myself while attending or participating in the
shooting sports programs or events for educational or media purposes. I grant WSU the right to use, publish, and
copyright my image (including audio, video or photograph) for educational program websites and promotion of
WSU/4-H programs.
I have read and reviewed the safety rules, range etiquette, behavior guidelines, and discipline specific rules for archery, rifle, shotgun, muzzle loader, pistol, or hunting. (applicable as noted above)
This is to certify as parent/guardian of this participant, I do consent to his/her release of the 4-H volunteers, other participants, WSU and it’s staff, donors, and the organizations providing and/or sponsoring
the range/meeting facilities and/or organizations’ volunteers and equipment from any and all liabilities
to his/her involvement in the 4-H Shooting Sports Program.
_________________________________
Parent/Guardian Signature
_________
Date
______________________________
Participant(s) Signature
________
Date
Washington State 4-H Shooting Sports
Consent of Parents
Medical Care and Treatment Form
This form must be completed for each participant when enrolled in the 4-H Shooting Sports program. This
information will be kept confidential and used only for the welfare of the participant.
Date_______________ Please Circle: Male Female
Birth Date __________Age____
Youth Last Name____________________ First Name____________________________
Address_________________________________________________________________
In case of emergency contact:
Parent/Guardian name___________________________ Phone ( ) _________________
_________________________________________Work Phone( )__________________
Other Ways to contact: Cell Phone ( )_______________Pager ( )_________________
Contact Person if Parent is not available _______________________________________
Relationship to child_____________________________ Phone ( )_________________
Physician’s Name/ Clinic _________________________Phone ( ) _________________
Health Insurance Company
Policy#
============================================================================
Requests for reasonable accommodations for disabilities or limitations should be made prior to
participation in the shooting sports program of or event. These project members may not be
participating in the same way as other youth members.
===========================================================================
Health History (check all that apply: giving appropriate dates where needed)
______Bronchitis _____Convulsions/ seizures
______Fainting
______Kidney Trouble _____Diabetes
______Heart Condition
______Recent Operations or Injuries
______Ear Infections
Asthma (controlled yes, no )
______
______Behavior Problems
Participant is allergic to:
Foods( specific)______________________ Tape? ______Rubber Gloves? ______
Latex? ______ Medication: prescription or non prescription drugs: Penicillin? ______ Aspirin? ______
Tetanus? ______ Other? _____________________________________
Serious Ivy, Oak or Sumac Poisoning ______ Bee or Insect stings _________________
Explain allergic reaction to allergies listed above________________________________
Prescribed Treatment______________________________________________________
Present dietary regulations__________________________________________________
Present Medications_______________________________________________________
Any specific activities to b restricted? _______________________________________
Immunizations; Tetanus: Date of last treatment _______________
Parent/Guardian Medical Release
This health history is correct as far as I know and the person herein described has permission to
engage in all prescribed activities, except as noted in writing by me , and the physician. In case of
emergency, I understand that every effort will be made to contact me. In the event I cannot be
reached, I give my permission to the physician selected by the adult leader in charge to hospitalize
and/or secure proper treatment for my child as named above. I, as parent or legal guardian, give my
consent. I assume complete responsibility for incomplete, incorrect, or lack of information on this
form. I do not hold the 4-H volunteers, WSU and or it’s staff, donors, other participants or the
organization providing and/or sponsoring range/meeting facilities responsible for accidents arising
out of this program. I understand that as the parent/guardian signing this form that I will be held
financially responsible for any expenses above and beyond what the 4-H insurance will pay. I will notify
in writing the volunteer/adult leader in charge if there is any changes in my child’s health condition and
or medications prior to any event or activity.
Signature of Parent/Guardian _________________________________Date________