University of Illinois Extension – Carroll, Lee, and Whiteside County
2016 Unit 4 4-H CAMP
APPLICATION
Lutheran Outdoor ministry Camp, Oregon IL
June 12-16, 2016
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 2015) ______ Age_____ Gender ______
City________________________________State_____________Zip____________County _______________
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, 2015 and have to have graduated from
8th grade order to participate as a CIT in 2016. All youth interested in taking part in CIT
Purchase a Camp T–Shirt
If your child would like a camp T-Shirt please mark size below (All shirts are adult sizes)
NOTE: Shirts will add $10.00 to your final camp bill
Size:
____ SM
____ MED
____ LG
____ XL
____ XXL
Camp Fee Schedule:
Register before April 1…………………………….$270
(Paid in full by June 1, or price goes up to $300)
Register April 1 thru June 1………………………..$300
(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/ Per camper
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.
Camp Awards & 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.
Please explain your request for financial assistance:
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, 2016 will be entitled to a full refund of the camp fee.
 Cancellations made between April 26 and May 4, 2016 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, 2016 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
12923 Lawrence Road
Sterling, IL. 61081