For 4- & 5-year olds
turning 4 &/or 5 at time of camp
(& not in kindergarten in spring, 2017)
DATES: June 5-8 @ Vermillion County Fairgrounds, Cayuga
June 12-15 @ Salem UMC, Clinton
TIME: 8:00 AM- 12:30 PM
FEE: $20
BRING: A sack lunch and a smile daily
WEAR: play clothes and shoes (no flip flops, please)
Participants will complete projects for exhibit at the Vermillion County
Fair (June 16/23), participate in age-appropriate activities/songs, &
make new friends!
Questions? Call Becky @ 765-492-5337
or e-mail: [email protected]
*********************************************
CLOVERBUD CAMP REGISTRATION
NAME _________________________________________ M______ F_______
Mailing Address__________________________________________________
Street/P.O. Box
______________________________________________________________
City
State
Zip
Parent E-mail___________________________________________________
Phone______________________ DOB_______________________________
Mother______________________ Father_____________________________
Check only one: ___ Fairgrounds (June 5-8) ___ Salem (June 12-15)
Parent Signature_____________________________________________
Please return with fee and signed health form BY
Vermillion County 4-H
703 W PARK ST SUITE #1
Cayuga IN 47928
MAY 15th to:
Make checks payable to Vermillion County 4-H
4-H CLOVERBUD CAMP
DAY CAMP HEALTH FORM
Child's Name___________________________________ Home Phone______________
Parent/Guardian__________________________________________________________
In case of emergency, contact___________________________ at____________(phone)
Please list any known allergies/medical conditions or medications that your child needs
that camp staff/medical personnel should be aware of:
______________________________________________________________________
______________________________________________________________________
In the event of emergency, I understand that first aid will be administered. Should serious injury
occur, parent/guardian will be notified. If it is impossible to contact us, I hereby give permission
for necessary medical treatment to be administered.
Parent Signature________________________________ Date___________________
Liability Release Statement:
I understand that participating in 4-H activities can involve certain risks to my child. On behalf of my child I accept those risks. I
hereby release and discharge Purdue University, The Trustees of Purdue University, the Vermillion County Commissioners, the
Vermillion County Cooperative Extension Service and each of their trustees, officers, appointees, agents, employees, and volunteers
("Released Parties") from all claims which my child or I might have for any injury or harm to my child, including death, arising out of
my child's participation in any activity related to the 4-H youth development program, even if such injury or harm is caused by the
negligence or fault of any of the released parties.
____________
Parents Initial here (Required)
Parent/Legal Guardian Statement:
I (we) understand, agree to abide by, follow, and comply with the rules, policies and expectations of the 4-H program and will
conduct myself (ourselves) in a courteous and respectful manner by exhibiting good sportsmanship and being a positive role model
for youth. I (we) also understand that failing to do so will constitute grounds for sanctions and/or dismissal of the member from the
program.
_______________________________________
Parent/Guardian Signature (Required)
Member Statement:
I agree to follow the rules, policies and expectations of the 4-H program and will conduct myself in a courteous and respectful
manner by exhibiting good sportsmanship and good behavior. I understand that failing to do so will result in sanctions, discipline,
and/or dismissal from the program.
_______________________________________
4-H Member Signature (Required)
Photo Policy Statement:
I (we) grant permission to the 4-H Youth Development program to use videos or photographs of my (our) child for educational
purposes or promotion of 4-H and/or Purdue Extension programs in local media.
_______________________________________
Parent/Guardian Signature (Required)
It is the policy of the Purdue University Cooperative Extension Service that all persons have equal opportunity and access to its educational programs,
services, activities, and facilities without regard to race, religion, color, sex, age, national origin or ancestry, marital status, parental status, sexual
orientation, disability or status as a veteran. Purdue University is an Affirmative Action institution. This material may be available in alternative formats.