4-H RES-Q Summer Day Camp Registration Form

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					                                                                                   4-H RES-Q 2009 Summer Day Camp
                                                                                           Registration Form

       Please Please fill out a separate form for each registrant.                                                         Camper ages: 7 – 12 years
       Hours: Tuesday – Friday, 9:00 am – 3:00 pm each day (sessions 1-6)
       Monday – Friday, 7:30 am – 5:30 pm each day (session 7, Aug 3-7)

                                         MUST HAVE A MINIMUM OF 10 CHILDREN FOR CAMP
                                                  st                         nd                     rd
SessioSession Dates - (Place 1 by your 1 choice, 2 by your 2 and 3 by your 3 )
                st                nd               rd               th              th                                            th                      th
               1                2                 3               4               5                                              6                   7
             Session          Session          Session          Session         Session                                       Session             Session
         June 16-19       June 23-26        July 7-10       July 14-17      July 21-24                                     July 28-31            Aug 3-7

       Child’s Name                                                                  Age                       Check one:               Boy        Girl

       Parent/Guardian Name


       City                                                                          State                     Zip

       Phone                                                 E-mail

       T-Shirt Size         Youth:           S         M    L                          Adult:            S     M       L

       How did you hear about RES-Q Summer Day Camp?                                  Returning Camper               Friend      Kid’s Directory

           Flier (school)                                                      L.R. Family Camps Guide                Other

       Check one:           White        Black/African American   Am. Indian/Alaskan Native     Hawaiian/Pacific Island
                            Asian        Two or More Races/Other Race Check Ethnicity:      Hispanic
       This information is requested solely for the purposes of determining compliance with federal civil rights laws, and your response will not affect your
       eligibility to participate in Extension programs. By providing this information, you will assist us in assuring that this program is administered in a
       nondiscriminatory manner
       Please mail this registration form and check (made payable to CES) as soon as possible to address below. (Make copies for
       your records)
               Registration fee is $150.00 per child per 4 day session. Fee includes a day camp Tee-shirt.
               Registration fee is $250.00 per child for the 5 day session. Fee includes a day camp Tee-Shirt.
       Camp fee (less $25.00 processing fee) will be refunded if cancellation is at least 2 weeks prior to your camp start date.
       Cancellations made less than 2 weeks before your camp start date will result in no refund.

       Your will receive a health/activity form, code of conduct and publications release after the registration form and check
       have been received. If you do not receive within a week, please call.

       If you have any questions, please contact:
       Mike Simmons
       4-H RES-Q Summer Day Camp Coordinator
       Arkansas 4-H Center
       #1 4-H Way
       Little Rock, AR 72223
       501-821-6884 or msimmons@uaex.edu

                         University of Arkansas, United States Department of Agriculture and County Governments Cooperating.

                    The Arkansas Cooperative Extension Service offers its programs to all eligible persons regardless of race, color,
                  national origin, religion, gender, age, disability, marital or veteran status, or any other legally protected status, and is
                                                     an Affirmative Action/Equal Opportunity Employer.