alternate application form fillable pdf format

MEMBER INFORMATION:

Name: ________________________________________________Birth Date: _____________

Address: ____________________________________________________________________

City: ________________________State: ______ Zip: ___________

Telephone: _________________      Email: __________________________________

Age (as of today) ________                             Male / Female/ Prefer not to state/ Gender not listed (please circle)

Parent/Guardian Name: _____________________________________________________________

Parent/Guardian Phone Number: ______________________________________________________

 

T-SHIRT ORDER:

A souvenir t-shirt will be available for this year’s 4-H camp. The t-shirt is included in the registration fee.

YOUTH SIZES                                                                      ADULT SIZES

_____ Medium (10-12)                                               _____ Medium           _____ X-Large

_____ Large (14-16)                                                   _____ Large               _____XX-Large

_____ X-Large/Adult Small (18)                                                                   _____XXX-Large

                                   

CAMP INFORMATION:

Has your child attended an overnight camp before? Yes _____No _____

 

Mark any of these supervised activities that will be at camp in which the camper is NOT allowed to participate:

______ Swimming                  ______ Team Building

______Nature Hikes               ______ Other activity not specified

______ Archery                      Activity not allowed: (please state activity) _____________________________

 

My Child has permission to engage in all camp activities except those noted above.

Parent/Guardian Signature: ______________________________________________Date__________

 

My child will be picked up by (adult picking up youth): ____________________________________________

(If you do not know at this time, please be prepared to let camp staff and your agent know at the time of check in who will be picking up your child.)

 

Please list any allergies your child has: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Please list any medication your child will be bringing to camp: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

For Office Use Only

 

Check# ___________Cash _____________Amount __________ Date Received _________