Print the 4-H Camp Registration Form

July16-18 at Camp Rotary

For Office Use Only:

Payment Amount:

Ck Number: 

Or

Cash:

Amount:

Received By:

Date Received:

 

Please Complete the following: 

Name:

Club:

Address:

Name of Parent or Legal Guardian:

Phone Number:

Grade in School (current year):

*Age (as of Oct. 1 of the current 4-H Year):

Two friends I would like in my cabin are:

 

Please complete this form and return with payment by June 15 to:

MSU Extension Office in Teton County

P.O. Box 130, Choteau, MT 59422

 

After June 15, a $10 late fee will be charged.

Please make all checks payable to: Teton County 4-H Council

NO REFUNDS AFTER JULY 1

 

List any additional information that would be helpful:

 

 

Enclosed is my registration and t-shirt fee (t-shirt purchase is OPTIONAL):

$50  x ­              =  $                       first Teton County 4-H member from family

$45  x               =  $                       additional Teton County 4-H members from same family

$25  x               =  $                       camp counselor rate

$20  x               =  $                       0-8 year old attending with a parent/guardian/adult

$100 x              =  $                      non-4-H member

$12   x              =  $                       t-shirts (optional)

TOTAL                  $

 

Please put number of each t-shirt size (IF purchasing):

Children’s:                      x-small              small                 medium              large

Adult’s:                          small                 medium              large                 X-large       XX-large
The person picking my child up at camp:            
Person(s) not permitted to take my child from camp:

  • Youth younger than 8 by October 1, need to have an adult attending with them. Youth older than 14 (and not serving as counselors) may be interviewed or screened to determine
  • A letter will be sent to all attendees after registrations are received with further details related to We will also develop a list of those attending camp to assist in carpool arrangements.
  • Montana State University Extension encourages persons with disabilities to participate in its programs and If you anticipate needing any type of special accommodations or have questions about the physical access provided, please contact the MSU Extension Office in Teton County at 466-2491 as early as possible in advance of your participation or visit.  Ten working days before the program is reasonable.

 

Medical Release Form for 4‐H Youth & Adults

 PARTICIPANT INFORMATION:                                                                                                                                           

Name:                                                                                 County:

Address:

Name of Parent or Legal Guardian: (YOUTH ONLY):

Primary Physician:                                                                                                  Phone:

Dentist:                                                                                                                     Phone:

IN CASE OF EMERGENCY:

Primary Contact:                                                                Phone:
Relationship:                                                                       City:                                                   State:

Alternate Contact:                                                              Phone:
Relationship:                                                                       City                                                     State:

INSURANCE INFORMATION

Name of Insurance Carrier:

Policy Holder Name:                                                         Policy #:

Date of Last:

Tetanus Shot:

Polio Shot:

Mumps Shot:

Measles Shot:

Rubella Shot:

Medical Information: (check next to all that apply and explain if necessary)

       Stomach or Intestinal problems

       Diabetes or hypoglycemia (low blood sugar)

       Nervous disorder (convulsions, epilepsy, dizziness, etc)

       Respiratory problems

       Heart Disease

       Any allergies to medication

      Any allergies to food or plants

      Special diet or food restrictions

      Are you currently under a doctor's care?

      Are you currently taking medications?

     Are there any physical restrictions or medical problems that may require special considerations? 

 

 

AUTHORIZATION FOR TREATMENT (YOUTH ONLY)

 

I,                                                                         do herby give permission to

            PARENT/GUARDIAN Name                                                                                             CHAPERONE Name
                     
to seek and obtain any medical care necessary for my child                                                                                   
                                                                                                                                         YOUTH Participant Name

Parent/Guardian Signature                                                                      Date 

ALL PARTICIPANTS                                                                                                                                             

To the Best of my knowledge, accurate information has been provided in all areas of this form.

Participant Signature (youth/ adult)                                                                                                Date 

IF YOUTH: Parent/Guardian Signature                                                                                          Date

                       

The Montana State University Extension Service is an ADA/EO/AA/Veteran's Preference Employer and Provider of Educational Outreach.