Winnebago County 4-H Camp
Upham Woods Outdoor Learning Center, July 21-24, 2016
Get your application in early to reserve a spot at camp!
Date:
Camper Name:
__________________________________________________________
Address: _____________________________ City, State & Zip: __________________________________________
Primary Phone: ________________________ Additional Phone: __________________________________________
Age: _____
Date of Birth:
_____/_____/_____ M or F
(Circle one)
Grade:
___________
2015-2016 School Year
E-Mail Address: ___________________________________________________________________________________
4-H Member:

TRADITIONAL
CAMP
 No
Yes
4-H Club Name: _____________________________________________________
Youth in grades 3-8. Held at Upham Woods Outdoor Learning Center. Activities include canoeing/ boating, hiking on irregular
terrain, archery*, general sports and challenge course. *Archery: I understand while shooting archery, it may be necessary for
the leader to position my child for proper stance and aiming for a safe shooting position. A leader may also need to adjust
safety equipment to prevent injury to the archer.
Outpost camp will
not be offered this COST: $80.00 for 4-H members/ $160.00 for Non-4-H members
year.
Do you have any roommate requests?
____________________________________________________________________
Residence (check one):
1.
 Farm
2.

Rural/10,000
 Hispanic
Race (check all that apply): 1.  White
Ethnicity (check one): 1.
T-Shirt – Adult Sizes Only:
3.  Town/10,000-50,000
4.  Suburbs/50,000>
5.
 Not Hispanic
2.  Black 3.  Alaskan/American Indian 4. 
5.  Hawaiian/Pacific Islander 6.  Two or more
Small _____

City/50,000>
2.
Medium _____
Large _____
Asian
X-Large _____
I require an accommodation for a disability to participate in this program.
 Yes
 No
I would like to discuss financial arrangements with a 4-H Youth Development Educator.
 Yes
 No
My child has my permission to attend 4-H Summer Camp at
Upham Woods Outdoor Learning Center, Wisconsin Dells, Thursday, July 21- Sunday, July 24, 2016.
Please note that Winnebago County UW-Extension may be taking videos and pictures of the participants at this event.
UW-Extension will use these videos and pictures in a manner consistent with UW-Extension’s mission. Your attendance at these
events indicates your consent for your image to be recorded and used in this manner.
Parent/Guardian Print: ______________________ Parent/Guardian Signature: ______________________________
NO REFUNDS after application is received!
Camp Application Deadline is Friday, June 3, 2016
Make check payable to: Winnebago County 4-H Leaders Association
Send payment with completed 4-H Camp Application to: UW-Extension 4-H Camp, 625 E County Rd Y
Suite 600, Oshkosh, WI 54901
An EEO/Affirmative Action employer, University of Wisconsin Extension provides equal opportunities in employment and programming including Title IX requirements.
Please make request for reasonable accommodations to ensure equal access to educational programs as early as possible preceding the scheduled program, service or activity.
For Office Use
Payment Received
Check Number