2015 4-H Camp Cherry Lake Residential Camp YES! I want to attend 4-H Camp Cherry Lake! July 6 – July 10, 2015 Indicate One: YOUTH CIT (COUNSELOR IN TRAINING – 13) COUNSELOR (14+) Name: ___________________________ Phone Number: __________________________ Mailing Address: ___________________________ City, State, Zip: __________________ Age: ___ Birthdate (8-9 year olds must provide proof of age): ___________ Grade Completed: ____ Gender: (check one) _____ Male _____ Female Ethnicity: (check one) Are you of Hispanic ethnicity? Race: (check one) ____ White Youth Adult _____ Yes _____ No ____ Black ____ Native Hawaiian/Pacific Islander T-shirt Size: _____ Other ____ Asian ____ American Indian/Alaskan ____Other SIZE: S M L XL XXL XXXL Emergency Contact Information: Primary Contact: ____________________ Phone: (____) _________ Relation: ___________ Alternate Contact: __________________ Phone: (____) _________ Relation: ___________ Each camper will attend fun workshops while at camp such as Kayaking/Canoeing, Swimming, Archery, Crafts, Recreational Games and much more! Cost: Cost of the camp is $190. Those qualifying for free & reduced meals pricing deduct $34.00 (this decision will be made by an office assistant based on income guidelines) The first 30 youth registrations qualify for a $50.00 scholarship. CIT (Counselors in Training) and Counselors completing training will qualify for $75.00 **Please ask for Counselor Application** Deposit of $25 (Required at time of registration) EXACT CASH, CHECK, OR MONEY ORDER ONLY – NO REFUNDS Checks must be made payable to: Levy Overall Advisory Committee Registration Deadline: All missing registration materials and payments must be received by Camp Orientation on Sunday, June 28th at 2pm. Hardship scholarships are available. Contact Lacy Harris or Albert Fuller. Return this form to: Levy County 4-H – PO Box 219, Bronson, FL 32621 Deposit: $25.00 Exact Cash or Check# ___________ Total Amount Due $__________ Exact Cash or Check# __________ Drivers License # (for written checks only) ____________________________ State Issued ___________________________ I certify that the information contained in this document is correct: ____________________________________________ ___________________________________________ Print Name Signature of Custodial Parent/Guardian