2017 Howard County4-H Camp Registration Form June 18Th June 24Th

2017 Howard County4-H Camp Registration Form June 18th – June 24th

UME is collecting information in order to enroll you in the UME sponsored Howard Co. 4-H Residential Camp. If you do not provide the requested information, your child may not be able to attend nor receive further information. The information you provide may be shared with UME and short-term appointed volunteers or instructors. Information provided to UME may also be shared among offices within the University and within the University System of Maryland and outside entities as necessary or appropriate in the conduct of legitimate University business and consistent with applicable law. Because the University is a State educational institution, such information may also be subject to disclosure under the MD Access to Public Records Act. Individuals may inspect and/or correct their personal information as provided by the “Public Records Act” and/or other applicable law or University policy.

Camper Information:

Last Name:______First Name:______Preferred Name:______

Address:______

City: ______State: ______Zip: ______

Race Data:This section is optional. It will be used for reporting purposes only.

What is your race? (Select one or more of the following categories):

☐ American Indian or Alaska Native ☐ Asian ☐ Black or African-American

☐ Native Hawaiian or Other Pacific Islander ☐ White ☐ Hispanic or Latino

Parents/Guardian Name: ______Cell #: ______

Parent /Guardian Name: ______Cell #: ______

Home Phone: ______DOB: ______

Sex: ☐Male ☐Female Age______(as of 1/1/2017)

T-SHIRT SIZE (Please Circle Size) YS YM YL YXL AS AM AL AXL AXXL

Does camper have any Dietary/Environmental/Medicine Needs: ☐Yes☐No

If yes, please explain: ______

Current HowardCounty4-H Member?☐Yes ☐No *Must be enrolled as of 1/1/17, priority until 4/15/17 for camp enrollment.

First year camper? ☐ Yes ☐ No If no, how many years have you been attending camp? ______

Name one camper you would like to share a cabin with:______

(Each camper is allowed one request only)

Name of sibling(s) applying:______

Information & Questionnaire:

Only if your child has a health condition or any condition that may require special care during camp, please complete this form.

Camper’s Name:______

Name of physician/health care provider:______Phone:______

Please indicate your child’s health condition or physical condition that may require special care:

Please describe, in detail the usual symptoms, or behaviors so that we may handle your child’s needs appropriately.

How do you treat this at home?

How would you like us to respond to this at camp (if it becomes necessary)?

Asthma/Epi-pen:

Does your child have Asthma? Yes__ No__

Does your child have an Inhaler? Yes__ No__

Does your child require the use of an epi-pen?Yes__ No__

If yes, will medication be required to be administered during camp?Yes__ No__

If yes, please follow instruction for the Maryland 4-H Camps Medical Clearance Form.

Other:

Does your child have any emotional or behavioral problems? Yes__ No__

Explanation:______

Has your child been diagnosed with ADHD or ADD?Yes__ No__

Does your child have an Individualized Education Plan?Yes__ No__

Is your child on any medication?Yes__ No__

If yes, please follow instruction for the Maryland 4-H Camps Medical Clearance Form.

______

Signature of Parent/GuardianDate

FULL PAYMENT REQUIRED WITH REGISTRATION:

☐Teen Leader $370 ☐Camper $420 (Ages 8-14 as of 1/1/17)

We are required to deposit checks immediately. This does not indicate acceptance of your application. Checks should be made payable to the Howard County EAC. The fee includes transportation to and from camp, food, lodging, supplies, other educational materials, postage for mailings, and insurance.

When the camp registration deadline has passed, additional information will be mailed to all applicants regarding acceptance. If not accepted, a refund check will be sent.

E-mail notification will be sent to confirm receipt of registration and payment.

Parents/Guardian Email Address for Communication Regarding Camp: ______

A limited number of full and partial scholarships are available for campers in need of financial assistance. We cannot guarantee that all who apply for a scholarship will be able to receive a scholarship. For scholarship forms, disability accommodation requests, or more information please contact Chris Rein via e-mail or at (410)313-1915.

RELEASE:

I, the undersigned, in consideration of my child’s participation in Howard County 4-H Residential Camp being conducted from June 18 – June 24, 2017 (for teen leaders beginning on June 17th), do hereby release, discharge, and forever hold harmless, University of Maryland Extension, all its employees, volunteers, and supporters thereof in connection with the aforementioned program, from any and all claims, demands, damages, actions, liability, or suits at law or in equity, for personal injury, whether physical or mental, property damage, medical, dental or hospital expenses or any other expenses of whatever kind, including death, which I may have had, now have, or may hereafter have, in any manner connected with, arising from or growing out of my participation in said program.

I, the undersigned, acknowledge that I sign this Release knowingly and intelligently and with full and complete knowledge of the purpose of said program and without any form of duress and/or intimidation whatsoever on the part of the University of Maryland Extension program.

Parent/Guardian Signature: ______Date: ______

A separate application should be completed for each child. Additional applications are available at Send completed registration application to:

University of Maryland Extension

Howard County 4-H Camp

3300 North Ridge Rd, Suite 240

Ellicott City, MD 21043

Note:

All items on this form MUST BE COMPLETED IN FULL and returned with full payment.

Registration forms which are not complete cannot be processed.

The University of Maryland Extension programs are open to any person and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, national origin, marital status, genetic information, political affiliation, and gender identity or expression.