4-H Tidelands Discovery Day Camp
Registration Form
At 4-H Tidelands Nature Center we encourage learning by doing. Our day camp provides youth an opportunity
to have fun, while gaining an awareness of the natural environment. Jekyll 4-H/Tidelands Nature Center’s
Discovery Day Camp is a part of the state-wide Georgia 4-H Environmental Education (EE) Program, provided
by five program sites in Georgia. The Georgia 4-H EE program began in 1979, and is now one of the largest
environmental education programs in the nation. (For further information, visit www.georgia4h.org/ee). This
year we will approach serving our millionth program participant! We welcome you as one in a million!
Please print, complete, and sign this form; along with the Medical Release and Code of Conduct form for each
camper attending. Send to 4-H Tidelands Nature Center: 100 S. Riverview Dr. Jekyll Island, GA 31527. Please
keep a copy for your records! Please call or email Dawn Zenkert with questions: dz@uga.edu, 912-635-5032.
Camper Information
Camper Name: ________________________________________ Age: ___________________________
Address (include city and zip): ___________________________________________________________
____________________________________________________________________________________
Are there any physical, medical, or dietary conditions that require special attention?
____________________________________________________________________________________
Is camper able to swim? _________________ Insurance Co. and policy #: ________________________
Day Camp Session
Please mark which Discovery Day Camp session your camper is attending
 June 17th-21st 2013
 July 15th- 19th2013
Days Attending Day Camp
Please mark which days of Discovery Day Camp your camper is attending
 Monday- Wonderful World of Water ($35)
 Tuesday- Creepy Crawlers ($35)
 Wednesday- Sand, Surf, and Shells ($35)
 Thursday- Super Sharks/Fantastic Fins ($35)
 Friday- Marsh Madness ($35)
 $15 Discount for all 5 daily programs ($160)
Number of days attending ___________ @ $35 per day= _____________ (Payment Due)
Please enclose a $50 non-refundable deposit or full payment by writing a check payable to:
Tidelands Nature Center. (See address above & include this form with payment)
Drop off: 10:00 am- Pickup: 3:00 pm @ Tidelands Nature Center
* Please note, there will be a $6 late fee for every 15 minutes after 3:00 pm. Please make sure there is a
parent or guardian available to pick up the camper at 3:00 pm each day.
Lunch/Snacks
Campers are expected to bring their own sack lunch and snacks each day. Meals are not provided by 4-H
Tidelands Nature Center. A convenience store is located nearby should parents need to pick up lunch/snacks.
What You Should Bring
Use the following checklist to make sure you bring everything you need for your day camp experience. *not required
We will be spending much of our time outside rain or shine, please dress appropriately. In the event of severe weather
we will provide activities indoors.
Monday
Tuesday
Wednesday
Thursday
Friday
Backpack*
Backpack*
Backpack*
Backpack*
Backpack*
Rain Jacket
Rain Jacket
Rain Jacket
Rain Jacket
Rain Jacket
Comfortable
Comfortable
Comfortable
Comfortable
Comfortable
Shoes (closed-toe) Shoes (closed toe) Shoes (closed toe) Shoes (closed toe) Shoes (closed toe)
Wear play clothes Wear play clothes Wear play clothes Wear play clothes Wear play clothes
Sunscreen/hat
Sunscreen/hat
Sunscreen/hat
Sunscreen/hat
Sunscreen/hat
Sack Lunch/Snack Sack Lunch/Snack Sack Lunch/Snack Sack Lunch/Snack Sack Lunch/Snack
Shoes that can be
Bug Spray
Change of clothes
Pair of old shoes
worn in the water
for seining (t-shirt
or boots to wear
(not flip flops)
& shorts, no
in marsh
bathing suits)
Shoes that can be
White t-shirt for
worn in the water
tie-dying
(not flip flops)
Parent/Guardian Information
First Contact Name: ______________________________ Employer: ____________________________
Address (if different): _________________________________ Day Phone: _______________________
Work Phone: __________________Cell Phone: __________________ Email: _____________________
Second Contact Name: ______________________________ Employer: __________________________
Address (if different): _________________________________ Day Phone: _______________________
Pick Up Permission
Please list any other adults besides those listed above who have permission to pick-up your camper. They may
be asked to show identification before the camper is permitted to leave.
(1) Name: ______________________________ Relationship: ____________________________
Address: ______________________________________ Phone: __________________________
(2) Name: ______________________________ Relationship: ____________________________
Address: ______________________________________ Phone: __________________________
Contacting your Camper
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If you need to contact your child for an emergency, call us at Tidelands Nature Center, 912-635-5032.
If no one answers, leave a message and we will return your call as soon as possible. Please realize,
campers may be outdoors and it may take time before we can return your call.
Discipline
To maintain a safe and cooperative setting, 4-H Tidelands Discovery Day Camp has policies in place for
camper’s behavior. If it becomes necessary to resolve or correct any dangerous or disruptive behavior, 4-H
Tidelands Nature Center staff will follow these guidelines:
1. Communication: Staff will discuss any problems with camper and together identify solutions available.
2. Time Out: Removal from a specific activity for a short period of time followed by further
communication between staff/camper.
3. Contacting Guardian: If the problem continues, administrator will contact the parent/guardian to
discuss further actions.
4. Dismissal from Program: The camper will be dismissed from the program and a parent/guardian will
need to pick him/her up if the behavior continues to be dangerous or disruptive to the other campers.
No refund will be provided if a camper must be dismissed.
Positive reinforcement is used to promote appropriate behavior. No physical discipline is allowed. Campers
are expected to be friendly and courteous to each other
Photo Release
I certify that I am the parent or legal guardian of _______________________. I give permission for my child to
be videoed, filmed, and photographed during the 4-H Tidelands Discovery Day Camp for the purposes of
developing promotional materials for the program. I understand that neither I nor my child will receive
compensation for the use of this video.
I hereby grant full permission to the University of Georgia, a division of the Board of Regents of the University
System of Georgia, to use, reproduce, publish, distribute, and exhibit my child's name, likeness, and voice in
connection with these materials.
I hereby release and forever discharge the University of Georgia, the Board of Regents of the University
System of Georgia, their members individually, and their officers, agents and employees, from any and all
claims, demands, rights, in my capacity as legal representative of my child, caused by or arising from the
production or use of these materials.
I understand that the acceptance of this consent and release form by the Board and Regents of the University
System of Georgia shall not constitute a waiver in whole or in part sovereign immunity by said Board, its
members, officers, agents, and employees.
Signature: _______________________________________ Date: _________________________
Printed name: ____________________________________ Relationship: ___________________
Emergency Procedures
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In case of emergency, 4-H Tidelands Nature Center staff will contact the local EMS and proceed as
directed, if required, to the appropriate local medical care facility (Southeast Georgia Regional Medical
Center Emergency Room).
Parents will be notified immediately of any emergency situation.
If parents cannot be reached, action will be taken as necessary according to the medical release form.
Tidelands staff are certified in CPR and First Aid and can act accordingly up to their training.
An incident report will be compiled and filed by the Tidelands Staff/Coordinator.
To be Read and Signed by Parent/Guardian and Child
I verify I have read and understand the information above and have provided accurate information on the
registration form. I hereby give my consent for __________________ (child's name) to attend 4-H Tidelands
Discovery Day Camp. I also hereby acknowledge that the above named child is in good health, or if applicable,
is subject to the allergies/medical problems/disabilities as listed on the 4-H medical release form. I agree that
the 4-H Tidelands Nature Center, 4-H, or the University of Georgia will not be responsible for any injury or
damage to my child or their belongings that may be sustained as a result of participation in camp activities.
Parent/Guardian Signature: ____________________________________ Date: _____________
To be read and signed by child and parent/guardian: I promise to follow the rules of good behavior and
conduct of 4-H Tidelands Nature Center. If I do not, the staff will speak to my parent/guardian. If the problem
persists, I may not be allowed to attend camp. I promise to get dirty/wet, ask questions, explore, try
something new, and have fun!
Camper Signature: ____________________________________________
Parent/Guardian Signature: _____________________________________
Directions
4-H Tidelands Nature Center is located at
100 S. Riverview Dr., Jekyll Island, GA 31527
From Brunswick, GA: Take the Jekyll (Downing Musgrove) causeway to Jekyll Island, GA. After you cross the
bridge onto Jekyll Island, take the very first right onto South Riverview Dr. Take S. Riverview Dr. for ½ mile and
Tidelands Nature Center will be located on the right, just before Summer Waves Water Park.