Clackamas County 4-H Cloverbud Day Camp Enrollment Form
Molalla, June 27 & 28
Sandy, July 11 & 12
Canby, July 14 & 15
Last Name _______________________________ First Name ______________________________ M.I. _______
Birth date ______________________ Age _________________ Grade completed at camp time ______________
E-mail(s) ______________________________________________________________________________________
Address _____________________________________ City ____________________ State ______ Zip ________
Accommodations: OSU and the 4-H Youth Development Program do not discriminate against otherwise qualified participants with
disabilities on the basis of disability. Are there any accommodations that you are requesting for yourself or your child in order to
participate in the 4-H Youth Development Program? No Yes, please describe _________________________________________
_____________________________________________________________________________________________________________
School Enrolled In: ____________________________________________________ Military Family? Yes No
If you do not want to be contacted by National 4-H Council, please check here
Ethnicity
Residence
Race
Not Hispanic
Farm
American Indian/Alaska Native
Hispanic
Small Town (under 10,000)
Asian
Large Town (10,000-50,000)
Black or African American
Suburbs of City
Native Hawaiian or other Pacific Islander
Gender
Female
City (over 50,000)
White
Male
More than One Race
Parent(s)/Guardian(s) ____________________________________________________________________________
Home Phone ______________________ Cell Phone __________________
Other Phone ___________________
T-Shirt Size
How did you hear about our camp?
Where will you meet the bus?
Youth Medium
4-H Newsletter
Canby – Baker Prairie Middle School
Youth Large
Newspaper
Molalla – TBA
Adult Small
Friend ________________________
Sandy - TBA
Adult Medium
Internet
Other - _________________________________
Other ________________________
I will not ride the bus
Notes: ________________________________________________________________________________________
Please make checks out to Clackamas County 4-H Leaders Association
$50.00
*Scholarship request - form needs to be attached
Fee Enclosed:
$20.00 deposit
*Scholarships are available to youth who meet eligibility for school free or reduced lunch program,
or families sending 3 or more children (from same household).
MEDIA RELEASE
I give permission to use camper’s image, in videotape, audiotape, film, photography, or in any other medium for educational,
fundraising, or promotional purposes related to the Oregon 4-H program. I understand that such images may be published in a
variety of ways, including, but not limited to, print and electronic formats. In addition, I give permission to release camper’s name
and hometown to news media for recognition purposes.
_________________________________________________________
___________________________________________
Parent Signature
Date
BOTH sides of this form MUST be completed!