DUE: June 5, 2016
Youth ages 5 – 7
Week 1 – July 6-8, 2016
** In order to operate the Clover Fun Days program, we require a minimum of 12 participants.
Families will be notified if we must cancel the session due to lack of participation.**
UME is collecting information in order to enroll you in the UME sponsored Carroll Co. 4-H Clover Fun Days. 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.
Sex of Youth:_______________ Birth Date:_______________
Parent/Guardian Name:_________________________________
Parent/Guardian Email:_________________________________
Parent/Guardian Phone No. (Home):_______________________
Parent/Guardian Phone No. (Cell): ________________________
This information is requested on an optional basis.
Your cooperation in providing it is appreciated.
Please check the box that indicates your race
which will be used only for reporting purposes.
 American Indian
 Black
 Oriental
 White
 Hispanic
Residence (choose one):
__A – on a farm;
__B – Rural area/town of 10,000 or less;
__C – Town/city of 10,000-50,000;
__D – Suburb of city over 50,000;
__E – City over 50,000
Parent/Guardian Phone No. (Work):_______________________
Is Camper a Carroll Co. 4-H member?: _________ Grade completed at end of current school year: _________
When: July 6-8, 2016 (Wednesday – Friday)
Where: University of Maryland Extension, Carroll County Office, Westminster, MD
Who: Youth ages 5 thru 7 as of January 1, 2016
Cost And Deadlines: All youth - $50.00 paid in full by June 5, 2016
Time: 8:30 a.m. – 4:00 p.m. – no lunch provided (participants must bring a lunch-refrigeration available)
Make your check payable to: CCEAC
Mail Application and payment to:
Carroll County Extension Office (4-H Clover Fun Days)
700 Agriculture Center
Westminster, MD 21157
Refunds: NO REFUNDS will be made after June 5, 2016 unless the program is cancelled due to lack of
Scholarships: Partial scholarships are available for youth in need of financial assistance. Call the Extension
Office (410-386-2760) to request a scholarship application. Scholarship Applications will only be
accepted until June 5.
If your child has a disability that requires special assistance for your participation in the Carroll County 4-H Clover
Fun Days, July 6-8, 2016, please contact the Carroll County Extension Office at 410-386-2760 or 1-888-326-9645 by
June 5, 2016.
In order to better accommodate your child’s needs, please list any medical concerns, disabilities, or special
needs of camper.
Please list any needed dietary accommodations, including vegetarianism.
Health statements, details on arrival time, what to bring, etc., will be mailed after June 5, 2016.
RELEASE: I, the undersigned, in consideration of my child’s participation in Carroll County 4-H Clover Fun
Days being conducted from July 6-8, 2016 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
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: ____________________
I give permission to the College of Agriculture and Natural Resources, University of MD, to use and publish my
photograph for educational and promotional purposes without compensation.
Youth Signature:_______________________________________________ Date:____________________
Parent/Guardian Signature ______________________________________ Date:____________________
The University of Maryland Extension programs are open to all 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.