University of Illinois Extension – Carroll, Lee, and Whiteside County
2013 Unit 4 4-H CAMP
APPLICATION
Lutheran Outdoor ministry Camp, Oregon IL
June 16-20, 2013 (Note Opening Day of Camp Change!)
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 2012) ______ Age_____ Gender ______
City________________________________State_____________Zip____________County _______________
Home Phone (___)_________________________ Hispanic or Latino  yes  no Race ________________
Email ___________________________________
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 June 14, 2013 in order to participate as a CIT in 2013.
All youth interested in taking part in CIT Training will be sent an application that they must fill out
and return prior to camp.
Camp T–Shirt:
Each camper will receive a FREE camp T-shirt!! (Note: All shirts are adult sizes)
Size:
____ XSM
____ SM
____ MED
____ LG
____ XL
____ XXL
Camp Fee Schedule:
Register before February 28……………………………..$255
(Paid in full by April 26, or price goes up to $265)
Register Feb 16 thru April 15…………………………….$265
(Paid in full by April 26, or price goes up to $275)
Register April 16 and later………………………………..$275
(Paid in full by June 1)
The registration dates are postmark dates.
OVER
Payment by Check or cash only due to the NEW allowable amount given to each 4-Her in C, L, & W:
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.
.
Scholarships:
1.
A limited number of camp scholarships may be provided to families expressing a need for financial
assistance. Applications for these scholarships will be distributed when the money becomes available
from the IL 4-H Foundation.
______
2.
3.
Check here if you would like to receive one of these applications.
A camp award to all Carroll, Lee, and Whiteside County 4-H members will be $150/child.
Contact your local Extension Office to see if additional camp scholarship opportunities are available.
Cancellations & Refunds
Upon receipt of a written request for cancellation, a refund will be made as stated below:
 Cancellations made before April 26, 2013 will be entitled to a full refund of the camp fee.
 Cancellations made between April 26 and May 4, 2013 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
April 4, 2013 will result in the loss of the entire camp fee.
I understand and accept these terms.
_____________________________________________________
Signature of Parent/Guardian
________________
Date
Mail application and fee to:
U of I Extension – Whiteside County
100 E Knox St
Morrison, IL 61270