Camp Cherry Lake Registration Form

2015 4-H Camp Cherry Lake
Residential Camp
YES! I want to attend 4-H Camp Cherry Lake!
July 6 – July 10, 2015
Indicate One:
YOUTH
CIT (COUNSELOR IN TRAINING – 13)
COUNSELOR (14+)
Name: ___________________________ Phone Number: __________________________
Mailing Address: ___________________________ City, State, Zip: __________________
Age: ___ Birthdate (8-9 year olds must provide proof of age): ___________ Grade Completed: ____
Gender: (check one)
_____ Male
_____ Female
Ethnicity: (check one) Are you of Hispanic ethnicity?
Race: (check one)
____ White
Youth
Adult
_____ Yes
_____ No
____ Black
____ Native Hawaiian/Pacific Islander
T-shirt Size:
_____ Other
____ Asian
____ American Indian/Alaskan ____Other
SIZE:
S
M
L
XL
XXL
XXXL
Emergency Contact Information:
Primary Contact: ____________________ Phone: (____) _________ Relation: ___________
Alternate Contact: __________________ Phone: (____) _________ Relation: ___________
Each camper will attend fun workshops while at camp such as Kayaking/Canoeing, Swimming,
Archery, Crafts, Recreational Games and much more!
Cost:
Cost of the camp is $190. Those qualifying for free & reduced meals pricing deduct $34.00
(this decision will be made by an office assistant based on income guidelines)
The first 30 youth registrations qualify for a $50.00 scholarship.
CIT (Counselors in Training) and Counselors completing training will qualify for $75.00
**Please ask for Counselor Application**
Deposit of $25 (Required at time of registration)
EXACT CASH, CHECK, OR MONEY ORDER ONLY – NO REFUNDS
Checks must be made payable to: Levy Overall Advisory Committee
Registration Deadline:
All missing registration materials and payments must be received by Camp Orientation on
Sunday, June 28th at 2pm. Hardship scholarships are available. Contact Lacy Harris or Albert Fuller.
Return this form to: Levy County 4-H – PO Box 219, Bronson, FL 32621
Deposit: $25.00 Exact Cash or Check# ___________ Total Amount Due $__________ Exact Cash or Check# __________
Drivers License # (for written checks only) ____________________________ State Issued ___________________________
I certify that the information contained in this document is correct:
____________________________________________
___________________________________________
Print Name
Signature of Custodial Parent/Guardian