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2010 4-H Camp Registration

 

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CAMPER INFORMATION
(please fill one registration out for each youth and adult participant)

CAMPER INFORMATION (please fill one registration out for each youth and adult participant)   First Name
Last Name
Address:
Address 2:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP/Postal Code:
County
Email Address:
Phone Number:

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Parent/guardian(s):

Parent/guardian(s):

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Date of Birth

	MM		DD		YYYY
Date of Birth	Date of Birth   Date of Birth   Month	/	Day	/	Year

Ethnicity

White/Not HispanicWhite/Hispanic

Ethnicity

Race WhiteBlackAmerican IndianAsianHawaiian and Pacific Islander Race

* Gender MaleFemale Gender

* Residence (please choose the type of community which best describes where you live) FarmTown (under 10,000 people)Suburb (10,000-50,000 people)Town (over 50,000 people) Residence (please choose the type of community which best describes where you live)

* Grade Completed June 2010 1st2nd3rd4th5th6th7th8th Grade Completed June 2010

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Are you currently enrolled as a 4-H member in Oregon?

yesno

Are you currently enrolled as a 4-H member in Oregon?

If Yes, please indicate which county

Name of School

Name of School

T-shirt Size

youth mediumyouth largeadult smalladult mediumadult large

T-shirt Size

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Name of Person(s) other than parents who can pick up camper

Name of Person(s) other than parents who can pick up camper

How did you find out about 4-H Camp?

How did you find out about 4-H Camp?   Information at school Ad in the Oregonian My 4-H Leader Email from 4-H office I attended 4-H camp last year Friend Other

OVERNIGHT CAMPERS: Special cabinmate requests

OVERNIGHT CAMPERS: Special cabinmate requests