5:30 PM 10:30 PM AT THE SOMERSET COUNTY 4-H CENTER CATERED DINNER DJ DANCING SERVICE PROJECT 4-H COURT OF HONOR WE HOPE TO SEE YOU THERE!

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1 5:30 PM 10:30 PM AT THE SOMERSET COUNTY 4-H CENTER CATERED DINNER DJ DANCING SERVICE PROJECT 4-H COURT OF HONOR WE HOPE TO SEE YOU THERE!

2 NJ 4-H Prom Saturday, July 1st 5:30PM - 10:30PM $35 per person Somerset County 4-H Building 310 Milltown Road Bridgewater, NJ All forms should be returned to the Bergen County 4-H Office by June 23 Please be sure to read the following information: 4-H ers who have completed grades 8-13 at the time of the event are invited. Each 4-H er may bring 1 non-4-h guest. This guest must also meet the grade requirement (completed grade 8-13). The cost is $35 per attendee, regardless of 4-H status. Each attendee must turn in a reservation form as well as an event permission form, by the June 23 rd deadline (print additional pages as necessary). Refreshments, a buffet style dinner and dessert will be served. 4-H ers who exemplify one of the four H s will be recognized as a member of the 4-H Court of Honor please see the nomination form in this packet for details. Service Project: formal wear and clothing donations should be brought on the day of the event (see the flyer in this packet for further information). All 4-H event rules and the code of conduct apply. Please ensure that 4-H ers and their guests behave in accordance with these rules. Any prom attendee who does not behave appropriately will be asked to leave the event. Space is limited! Reserve your space ASAP! PLEASE NOTE: The venue does not have air conditioning. So while we hope you will all dress to impress, please take this into account as you are planning your prom attire. This event is being organized by the 2017 National 4-H Conference New Jersey Delegates. Questions regarding the event can be directed towards: Kirsten Clerico, Somerset County: countrygal876@comcast.com Madeline England, Bergen County: pimaddypie@gmail.com Zachary Newman, Ocean County: newmanz1@aol.com Isha Thapar, Middlesex County: ishathapar1@gmail.com Shyanna Thompson, Gloucester County: shyanna113@aol.com Jillian Tozer, Cumberland County: jillian.tozer17@gmail.com Adult Partners: Laura Bovitz, Middlesex County 4-H Agent: bovitz@njaes.rutgers.edu Abbie Kesely, Bergen County 4-H Program Associate: akesely@njaes.rutgers.edu Lisa Rothenburger, Somerset County 4-H Agent: rothenburger@njaes.rutgers.edu

3 NJ 4-H Prom Reservation Form Each attendee must turn in an individual Event Permission form in addition to being listed on a Reservation Form. Name of 4-H Member: Grade: County: address: Parent/Guardian s Name: Home Phone Number: Mobile Number: Name of Non 4-H Guest: Grade: address: Parent/Guardian s Name: Home Phone Number: Mobile Number: I am purchasing: 1 ticket ($35)- for one 4-H member 2 tickets ($70)- for one 4-H member + one non-4-h guest (or two 4-H members) Please make all checks payable to: Somerset County 4-H Association Please send all forms with payment to the Bergen County 4-H Office at: Rutgers Cooperative Extension of Bergen County 1 Bergen County Plaza, 3 rd Floor/4-H Hackensack, NJ 07601

4 New Jersey 4-H Event Permission Form for Youth 4H104 Both sides of this form must be completed by all youth participating in overnight activities, field trips, events requiring group transportation, and any other events sponsored through the 4-H Youth Development Program where it is deemed necessary by the event coordinator(s) (paid 4-H staff and/or registered 4-H volunteer) responsible for the youth participants. The form should be submitted prior to the event. The form has five parts: (1) information about the participant and activity, (2) parental permission and liability release, (3) medical emergency authorization and health information, and (4) code of conduct and (5) media policy. Be sure to complete all five parts and sign where requested! Information about the Youth Participant and Activity Name of Youth participant: Address: Telephone number: City: State: Zip: Address: 4-H county: Birthdate: Grade: Name of activity/event: Name of 4-H group sponsoring or participating in this event: Location of event: Date and time of participation of individual named above: Parent Permission and Release of Liability I hereby give my son/daughter named above permission to participate in the event listed. Although Rutgers Cooperative Extension and its event coordinator(s) will use the utmost precaution in guarding the health of the above participant and preventing accidents, I release them from any liability in case of illness or injury as a result of this activity. Furthermore, I release the owner and driver of the car transporting my child to and from the event, from any liability in case of illness or injury. Signature of parent or guardian: Medical Emergency Authorization and Health Information I authorize the event coordinator(s) to dispense the prescription drugs and/or over the counter medications listed below in accordance with the instructions provided on the label (prescription drugs) or below (over-the-counter medications). In case of sudden illness or an accident to the above named participant requiring immediate treatment or surgery while he/she is a participant in this activity, I authorize the 4-H chaperone(s) to take such action as seems appropriate to protect the health and physical well-being of the above participant. This authority extends to any physician(s) and/or surgeon(s) selected by the event coordinator(s) to perform medical and/or surgical procedures including examinations and tests necessary to preserve the health and physical well-being of the above named participant. All efforts will be made to contact the parent(s) or guardian(s) in case of emergency. Name of parent/guardian Phone number Name of additional emergency contact Phone number The following information is provided as an aid to the event coordinator(s) in dealing with the well-being of the participant. The participant has the following health conditions: (include allergies, handicaps, diabetes, pregnancy, asthma, medications needed, etc.). Health conditions: Medications/Instructions: Health Insurance: Company Group# ID# Signature of parent or guardian Continued on other side

5 New Jersey 4-H Code of Conduct The primary purpose of the New Jersey 4-H Code of Conduct is to ensure the safety and well-being of all participants at 4-H sponsored events and activities. It applies to all participants, with participants defined as 4-H members, their parents, and volunteers. As a participant in the 4-H program, I will: Conduct myself in a courteous manner and treat members, parents, 4-H volunteers, Extension staff, judges and others with respect. Appropriate language and behavior are expected at all times. Respect and adhere to the rules and guidelines of the 4-H program including all those specific to a 4-H event or activity. Uphold an individual s right to dignity by supporting an environment of inclusion which welcomes involvement of participants from all backgrounds. Accept supervision and support from county and state 4-H staff while participating in the 4-H program. This includes acceptance of supervision and support from appointed 4-H volunteers coordinating 4-H events and activities. Obey local, state and federal laws. Participants who fail to adhere to the New Jersey 4-H Code of Conduct are subject to a range of disciplinary actions. Such actions will be taken in compliance with the New Jersey 4-H Discipline Policy and Procedure. When appropriate, immediate corrective action will be taken at the 4-H event to ensure the safety and welfare of all participants. I understand if I fail to adhere to the above Code of Conduct, I will be subject to disciplinary action and potentially prohibited from attending and participating in the New Jersey 4-H Youth Development program. Signature of participant in event Signature of parent or guardian Date Date New Jersey 4-H Media Policy and Release The 4-H program routinely promotes activities through various media. This includes, but is not limited to newsletters, newspapers, brochures, and displays. In doing so, the names and photos of members may be included to help tell the 4-H story. However, New Jersey 4-H policy is that on web sites, youth in photos will not be identified by name(s). No, do not use my individual picture for any purpose. I will make an effort to avoid opportunities to be in group photos. No, do not use my name for any purpose. Revised: January 2013

6 Nomination Form The Four H s Exemplified Please use this form to nominate ONE 4-H member (no self-nominations, please) that you believe embodies one of the four H s: Head, Heart, Hands, Health. Check off which H you believe they encapsulate and provide a brief description of why and how in the space provided below. The Prom Planning Committee will vote on the 4-H members who will be included in the 4-H Court of Honor at the Prom*. *Please note only those 4-H ers who will be attending the Prom will be considered. Name of 4-H Member you are nominating: County of 4-H Member you are nominating: HEAD HEART HANDS HEALTH This is a 4-H er who uses their head for clearer thinking. Someone who thinks outside the box, is innovative, and is always looking for better ways to do things, and improvements that can be made. This is a 4-H er who uses their heart for greater loyalty. Someone who is always willing to be an ear for listening and a shoulder for leaning. Someone who goes out of their way to make others feel welcome and included. This is a 4-H er who uses their hands for larger service. Someone who is always willing to help their club, their county, their community, and who creates excitement around community service projects and giving back. This is a 4-H er who believes in living healthy, and encourages others to do the same. Someone who is passionate about living their best life and inspires others to follow a healthy path. Please use the lines below to explain why you believe this 4-H member should be honored. Use the descriptions above as a guide, but feel free to include your own interpretation of what the H means to you. Use the back of this page if you need additional space.

7 NJ 4-H Prom **Community Service** Please considering donating to one of the following collections at the NJ 4-H Prom: Donations of gently used or new formal gowns and dresses will be collected and delivered to Project Prom, a grassroots organization that collects and distributes prom dresses to high school girls in need throughout Atlantic, Cape May, and Cumberland Counties, free of charge. Please consider donating a dress if you have one! Donations of clothing, shoes, and small household items will be accepted and provided to the Vietnam Veterans of America organization. Please consider donating items that you no longer need or use!