Roanoke Valley 4-H Summer Camp (July 9-13, 2012) Registration Form

Campers Name___________________________________________________ Please circle Male / Female Parents/Guardians Names: Father ____________________________________________________________________ Mother __________________________________________________________________ Who has primary custody of camper? __________________________________________________________________ Home phone________________________ Parents Daytime work numbers ___________________________________ Parents/Guardians cell numbers _____________________________________________________________________ Parents/Guardians email addresses ___________________________________________________________________ Home street address ________________________________________________________________________________ City _____________________________________ State _________________ Zip ______________________________ Campers age as of 9/30/12______ Birth date _________ Grade in School______ School _________________________ Race of camper (please check all that apply) Non-Hispanic Hispanic Asian American Indian or Alaskan Native African-American or Black White Native Hawaiian or other Pacific Islander More than one race Undetermined Roanoke County Roanoke City Salem Other _________________________ Residence of camper Small Medium Large XL T-Shirt size (adult sizes only) Parents/Guardians: Cost for our camp this year will be $260. This includes transportation to and from the 4-H Center on buses, meals, lodging, and Camp t-shirt. A deposit of $100 or more is required when we receive the application in order to hold your childs place at camp. The remainder of the fee is due no later than June 8. Please make your check payable to VCERoanoke and mail along with registration form above to Roanoke 4-H Camp, 3738 Brambleton Ave., S.W., Roanoke, VA 24018. Refund deadline is May 21. Registration deadline is June 15. There is a $50 charge for returned checks, and up to a 30-day wait for refunds. Adult volunteers are a vital part of 4-H summer camp! If you are interested in becoming a volunteer, please call our office at 540/772-7524 for more information. A completed application with references is required. Adult male volunteers are in short supply, so Dads come on to camp with us!! Youll have a great time.

Leslie R. Prillaman, Extension Agent, 4-H Youth Development Please sign here if you are interested in becoming an adult camp volunteer ________________________________________ Daytime phone____________________________________

If you are a person with a disability and require any auxiliary aids, services, or other accommodations for this activity, please contact our office at 540/772-7524 10 days prior to camp.

OFFICE USE ONLY: Date received_________________ Receipt #__________________ Amount paid _________________

Virginia Cooperative Extension

A partnership of Virginia Tech and Virginia State University

Agriculture and Life Sciences

College of

2012 Roanoke Valley 4-H Summer Camp

July 9-13

At the W.E. Skelton 4-H Educational Conference Center at Smith Mountain Lake

For more information, contact the Roanoke 4-H Office 3738 Brambleton Avenue, Roanoke, VA 24018 Telephone: 540/772-7524 Emails: lesliep@vt.edu, amberkh@vt.edu

Camp is for youth ages 9-13 as of September 30, 2012

Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; Jewel E. Hairston, Interim Administrator, 1890 Extension Program, Virginia State, Petersburg