Camp Enrollment Form - Clackamas County 4-H Cloverbud Day printable pdf download

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!

Camp Enrollment Form - Clackamas County 4-H Cloverbud Day

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