LOG N to your NEXT CHAPTER Registration Form
Be a part of this annual leadership & college development opportunity!
LOG N Camp and Chapter 3: $80 for 2 day camp
Chapter 1, 2, 4 & 7 Habits: $40 for 1 day camp
Please make checks payable to University of Nebraska Lincoln. Payments can be sent to Box Butte County Extension, 415 Black Hills Ave, Alliance NE 69301

For questions please contact us either by email: Melissa Mracek: mmracek2@unl.edu, Sarah Paisley: spaisley3@unl.edu, Michell Garwood: mgarwood3@unl.edu, or Ashley Fenning: astevens4@unl.edu OR
By Phone: 308-762-5616 or 308-772-3311
Student First & Last Name *
Home Address *
City, State, Zip *
Parent/Guardian First & Last Name *
Parent Phone Number *
Student Phone Number
Parent Email *
Student Email *
What event will you attend? (Please mark one, this is the grade you are/were in during the 2020-2021 school year) *
Dietary restrictions *
Question: What do you see for yourself after High School? *
I understand that I will have to send in my payment prior to the event. (Mail payment to Box Butte County Extension, 415 Black Hills Ave, Alliance NE 69301) *
Are you a 4-H Member? *
Signature of applicant *
My student is allowed to participate in the LOG N to your NEXT CHAPTER group(s). If my student is a current 4-H member, I will fill out the health form found on 4HOnline. If my student is not a current 4-H member, I agree to fill out a paper health form before my child goes to camp. *
Signature of parent/guardian *
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