HOWARD COUNTY 4-H CAMP REGISTRATION
Howard County 4-H Day Camp July 12-16, 2021 8:30-4:30 Monday through Friday.
2021 4-H Day Camp Fee for the week is $200.00 (Ages 8-14 as of 1/1/2021) All payments can be made online at: https://go.umd.edu/HowardCountyCampPayment with a transaction, fee or check may be made payable to the Howard County EAC. (University of Maryland Extension 4-H Camp 3300 North Ridge Road Suite 240 Ellicott City, MD 21043) The fee includes snacks, and drink, supplies, other educational materials, postage for mailings, and insurance. Any questions please contact Chris Rein at Crein@umd.edu.
UME is collecting information in order to enroll you in the UME sponsored Howard Co. 4-H Day Camp. If you do not provide the requested information, your child may not be able to attend nor receive further information. The information you provide may be shared with UME and short-term appointed volunteers or instructors. Information provided to UME may also be shared among offices within the University and within the University System of Maryland and outside entities as necessary or appropriate in the conduct of legitimate University business and consistent with applicable law. Because the University is a State educational institution, such information may also be subject to disclosure under the MD Access to Public Records Act. Individuals may inspect and/or correct their personal information as provided by the “Public Records Act” and/or other applicable law or University policy.
Camper Last Name: *
Camper First Name: *
Preferred Name:
Address: *
City: *
State: *
Zip: *
Household Email Address: *
Race Data: This Section is optional: It will be used for reporting purposes only. What is your race?
Clear selection
Residence (choose one) Data: This Section is optional: It will be used for reporting purposes only.
Clear selection
Parents/Guardian Name: *
Cell Number: *
Parents/Guardian Name:
Cell Number:
Home Addres: *
Camper Date of Birth *
MM
/
DD
/
YYYY
Gender: *
Age: ( as of 1/1/2021) *
T-Shirt Size *
Does the camper have any Dietary/Environmental/Medicine Needs: *
Required
If yes, please explain:
Currently a 4-H Member *
Required
If yes, what county are you a 4-H Member?
Name of siblings applying:
When the camp registration deadline has passed (June 21, 2021), additional information will be mailed to all applicants regarding acceptance. As well as some additional forms. If not accepted, a refund check will be mailed. E-mail notification will be sent to confirm receipt of registration and payment. Parents/Guardian Email Address for Communication Regarding Camp:
A limited number of full and partial scholarships are available for campers in need of financial assistance. We cannot guarantee that all who apply for a scholarship will be able to receive a scholarship. For scholarship forms, disability accommodation requests, or more information please contact Chris Rein via e-mail crein@umd.edu or at (410)313-1915.
Information and Questionnaire: Only if your child has a health condition or any condition that may require special care during camp please complete the following questions. Camper's Name:
Name of physician/health care provider:
Telephone number for physician/health care provider:
Please indicate your child's health condition or physical condition that may require special care:
Please describe, in detail the usual symptoms, or behaviors so that we may handle your child's needs appropriately.
How do you treat this at home?
How would you like us to respond to this at camp(if it becomes necessary)?
Does your child have Asthma? *
Required
Does your child have an Inhaler? *
Required
Does your child require the use of an Epi-pen? *
Required
If, yes will medication be required to be adminstered during camp? If, yes please follow instructions for the Maryland 4-H Camps Medical Clearance From. Accessed at www.howard4-H.org
Does your child have any emotional or behavioral problems? *
Required
If yes, please explain:
Does your child have an Individualized Education Plan? *
Required
If, yes is there any information that would help us to better work with your child.
Is your child on any medication? *
Required
If yes, please follow the instructions for the Maryland 4-H Camps Medical Clearance Form. Accessed at www.howard4-H.org
RELEASE: I, the undersigned, in consideration of my child’s participation in Howard County 4-H Day Camp being conducted from July 12-16, 2021, I do hereby release, discharge, and forever hold harmless, University of Maryland Extension, all its employees, volunteers, and supporters thereof in connection with the aforementioned program, from any and all claims, demands, damages, actions, liability, or suits at law or in equity, for personal injury, whether physical or mental, property damage, medical, dental or hospital expenses or any other expenses of whatever kind, including death, which I may have had, now have, or may hereafter have, in any manner connected with, arising from or growing out of my participation in said program. I, the legal guardian, acknowledge that I Release knowingly and intelligently and with full and complete knowledge of the purpose of said program and without any form of duress and/or intimidation whatsoever on the part of the University of Maryland Extension program. *
Required
Once you received your email confirmation. Please access the following forms and complete at www.howard4-H.org. Payment and all forms must be in the office by June 21, 2021.
Column 1
Column 2
Column 3
Column 4
Column 5
Camp Health Form
Camp Policy for Campers and the Internet
Informed Consent -Youth
Photography Release Form
Camp Sunscreen Authorization Form
Clear selection
Submit
Never submit passwords through Google Forms.
This form was created inside of University of Maryland, College Park. Report Abuse