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PAYMENT &
REGISTRATION INFO
4-H Camp pre-registration form
Camp Dates: Monday, June 29 —Friday, July 3, 2015
Camp Fee: $230
We take a limited number of campers to 4-H camp.
Spots are filled on a first come, first served basis.
To reserve your spot at 4-H Camp,
please complete and return the
attached pre-registration form.
Additional registration materials will be
sent for you to complete.
Please Print all Information
Child’s Name_____________________________________________Date____________________
Address_____________________________________________________________________
City________________________________ State____________ Zip Code_____________________
Gender (Circle One) Male / Female
Race*_______________________________________
(*Necessary to comply with affirmative action – Civil Rights Standard)
Have you attended 4-H Camp before? ________If so, how many years?_______________
School ________________________________________ Grade ______
Age____________________
Birthdate____________/______/______
Do you qualify for the Free/Reduced Lunch Program? (Circle One)
Yes / No
Camper would like to bunk with:____________________________________________________
Custodial Parent(s)/Guardian(s) Name: (please print)_____________________________________
Signature:__________________________________________ Home Phone ______________________
Work Phone ___________________________ Cell____________________________________
Email___________________________________________________________________________
Please Circle Camper’s T-shirt Size:
YM YL AS AM AL AXL
Make Checks Payable to
Oldham County 4-H Council
Please Return to:
Oldham County 4-H
Cooperative Extension Service
1815 North Highway 393
LaGrange, KY 40031
502-222-9453
For Office Use Only
Received ___________________________________
___________________________________________
Cash
Ck #
$
List
DB
App
** After we receive the pre-registration form and payment, you will receive the entire
camp application that will need to be completed before your child can attend camp. A
physical is required for camp attendance**
$115 Deposit with Pre-Registration and
the remaining $115 with completed
registration packet due by Wednesday,
May 27, 2015
OR
One Check for $230 with Pre-Registration
There is a $30 fee for all returned
checks.
NOTE THERE IS A $30.00 CANCELLATION
FEE AFTER Wednesday, May 27, 2015.
PLEASE MAKE CHECK PAYABLE TO:
Oldham County 4-H Council and mail to
Oldham County Cooperative Ext.
1815 North Highway 393
LaGrange, KY 40031
Phone: (502)222-9453
Fax: (502) 222-7930
4-H
Camp
Decades
Throw Back
At
Lake Cumberland
In
Jabez, KY
Monday– Friday
June 29– July 3
Phone: (502) 222-9453
Fax: (502) 222-7930
Kelly Woods
Extension Agent for 4-H Youth Development
kwoods@uky.edu
Educational programs of Kentucky Cooperative Extension
serve all people regardless of race, color, age, sex, religion,
disability, or national origin.
Challenge Course
Nature
Recreation
Sports
Team Building
Fishing
And Much More
See all the fun in our camp
video online at
Living
Accommodations
Campers stay in cabins with
teen and adult leaders. Boys
and girls are in separate cabins.
If you would like to bunk with a
friend, please indicate their
name on the pre-registration
form.
http://ces.ca.uky.edu/
oldham/4HCamp
Adults pay no fees to attend camp.
The first 16 leaders to volunteer will
receive a discount on their family's
camp fees.
If you would be interested in serving
as an adult cabin leader, please
complete the attached adult leader
interest form and return it to the
Oldham County Cooperative Extension Service, 1815 North Highway
393, LaGrange, KY 40031.
You will be contacted by the 4-H
agent.
Please list any leadership positions you have had in schools, churches, 4-H, etc.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Why do you want to be a camp volunteer leader?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Arts / Crafts
Male _____ Female _____ Have you attended camp as an? Adult ________________ Youth ____________________
Rifle / Archery
Home Phone __________________ Work/Cell Phone ____________________ Email ___________________________
Canoeing
City _______________________________State ___________________________ Zip Code _______________________
Swimming
We depend on parents of
4-H
campers to attend camp and serve
as adult cabin leaders. During the
week they attend classes with
campers, join in all the fun, and are
responsible for keeping their cabin
group safe and happy. Training is
provided for camp leaders.
Address ___________________________________________________________________________________________
Our camp fills up quickly!
Complete pre-registration forms
and return them promptly!
All Classes are taught by our
certified instructors using approved
curriculum. Activities and classes
include:
Name___________________________________________________________________ T-shirt size _______________
Boys and girls from Oldham
County ages 9 - 13 and 8 year
olds entering fourth grade.
PARENTS: We Need
Your Help!
Please complete this section if you would like more information about being an adult leader at camp.
Who May Attend?
What do Campers do
at 4-H Camp?