4-H Adventure Day Camp

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WHERE: Neligh Park in West Point

WHEN: June 7, 2024

7:45 - 8:00 a.m. (Check in)
8:00 a.m. - 3:30 p.m. (Camp)

WHAT: Be prepared to have fun! Wear clothes that can get dirty

BRING: Bug Spray, Sun Screen, Extra Set of Clothes, Life Jacket (if you have one)

COST: $40.00 per youth

AGES: Open to youth ages 8-11 as of January 1 of the current year

REGISTRATION DEADLINE IS FRIDAY, MAY 31, 2024. MAKE CHECKS PAYABLE TO: UNL

Questions? Contact the Cuming County Extension Office at 402-372-6006.

**The University of Nebraska does not discriminate based upon any protected status. Please see go.unl.edu/nondiscrimination.

Email *

Youth First Name *

Youth Last Name *

4-H Age (As of January 1 of the current year) *

Age 8

Age 9

Age 10

Age 11

Required

4-H County *

Are you attending as a 4-H Counselor? If so, please put your first and last name and 4-H county below.

**4-H Adventure Day Camp Counselor Training will be held on Tuesday, June 4th from 5:00 - 7:30 p.m. at Neligh Park in West Point. We ask that all youth assisting as camp counselors attend if possible.

Address *

City, State, Zip *

Parent/Guardian Name *

Parent/Guardian Phone Number *

Emergency Contact Name & Phone Number *

I want to be grouped with (ONE NAME ONLY) *

*Note, accommodations can be made if you need to pick up your child/children after 4:00 p.m. but no later than 4:30 p.m. Please indicate if you will need to pick up after 4:00 p.m.
*

PERMISSION TO TREAT, PARTICIPATE, AND RELEASE OF CLAIMS

Nebraska Extension Staff and volunteers at Adventure Day Camp will do all within their power to ensure the safety of your child during the camp activities. To help ensure a successful 4-H experience, it is vital that we know about our participants' unique needs or concerns. Please list below anything that will better help us understand your child. List any activity restrictions, adaptations, special learning considerations or other relevant experiences below.

1. Please list below any medications your child will bring with them to Adventure Day Camp.

2. Please list any allergies below.

Please check all statements below that you agree to and sign.
*

I give permission to use my child's name / photo in publications, ads, news articles, videos, websites or other electronic media pertaining to 4-H.

My child does not take medication on a regular basis

If deemed necessary, I (parent/guardian) give permission to administer non-prescription medications in accordance with directions on the label for headaches, upset stomach, diarrhea, menstrual cramps, and poison ivy.

In the event of a medical emergency, the Nebraska Extension staff & volunteers have my permission to take whatever measures they deem reasonable to render assistance and that I and/or family will be financially responsible for any expense involved.

Required

Parent Signature

By signing, I am agreeing to pay the $40 registration fee for my child to attend 4-H Adventure Day Camp. All payments are final, no refunds.

Payment is due by FRIDAY, MAY 31 TO THE CUMING COUNTY EXTENSION OFFICE.

Make checks payable to: University of Nebraska-Lincoln

I will be ...

Dropping payment off at the Cuming County Extension Office

Mailing a check to the Cuming County Extension Office (Must be postmarked by May 31)

Date *

YYYY

Send me a copy of my responses.

Submit

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