DUE: June 5, 2016 ONE APPLICATION PER CAMPER CARROLL COUNTY 4-H CLOVER FUN DAYS APPLICATION FORM 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. Name:_______________________________________________ Address:_____________________________________________ ____________________________________________________ Sex of Youth:_______________ Birth Date:_______________ Parent/Guardian Name:_________________________________ Parent/Guardian Email:_________________________________ Parent/Guardian Phone No. (Home):_______________________ Parent/Guardian Phone No. (Cell): ________________________ RACE DATA 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 participation! 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 program. 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.