4-H membership is NOT required to participate. One application per camper, please.
Include an e-mail address, if possible, so that we may confirm your registration and send information.
Camper Information:
Camper’s Name _________________________________________ Birth Date _____/______/________
Address______________________________________ Grade ( Fall of 2014 ) ______ Age_____ Gender ______
City________________________________State_____________Zip____________County _______________
Home Phone (___)________________ E-mail ___________________________________________________
If currently enrolled in 4-H, what county and club? ________________________________________________
Parent Information:
Mother’s Name____________________________ Father’s Name__________________________________
Address (if different than above) Address (if different than above)
________________________________________ ______________________________________________
________________________________________ ______________________________________________
Mother’s Cell Phone: ______________________ Father’s Cell Phone: ______________________________
If you would like to bunk with another camper please put his/her name here: _______________________
Please Note: This is not a guarantee that you will be bunking in the same cabin. Cabin assignments are based on age, grade, and time of camper registration.
________ Please mark here if you would like to apply to take part in CIT Training (Counselor In Training), during camp week. You must be 14 by September 1, 2014 and have to have graduated from
8th grade order to participate as a CIT in 2015. All youth interested in taking part in CIT
Camp T
–Shirt & 4-H Water Bottle
Each camper will receive a FREE camp T-shirt and water bottle!! (Note: All shirts are adult sizes)
Size: ____ SM ____ MED ____ LG ____ XL ____ XXL
Camp Fee Schedule:
Register before April 1 …………………………….
$260
(Paid in full by June 1, or price goes up to $280)
Register April 1 thru June 1 ………………………..
$280
(Paid in full by June 1)
The registration dates are postmark dates. OVER

Payment by Check or cash only:
A minimum $75 deposit must accompany this application form .
All final payments must be received before June 1 or a bunk will not be held for the camper.
Please make all checks payable to University of Illinois Extension.
Your application must also be mailed to the Whiteside County Extension Office at the address below by the listed deadline, to complete your registration.
Financial Assistance:
1. The Unit will provide a limited number of financial assistance awards to those families who express a need. Please fill out the box below with information.
2. LOMC offers some financial assistance as well if you would like one of their applications please mark the space below.
*I would like more information for LOMC Financial Assistance ___
Cancellations & Refunds
Upon receipt of a written request for cancellation, a refund will be made as stated below:

Cancellations made before April 26, 2015 will be entitled to a full refund of the camp fee.

Cancellations made between April 26 and May 4, 2015 will be entitled to a refund of 50% of the camp fee.
 Unless there is a written doctor’s order stating that the child is unfit for camp, cancellations made on or after
May 4, 2015 will result in the loss of the entire camp fee.
_____________________________________________________
Signature of Parent/Guardian
________________
Date