CAMPER APPLICATION PACKET
                         4-H Great Lakes & Natural Resources (GLNR) Camp – August 1 to 7, 2010
Sections 2 to 4 of this form packet require a separate signature by a parent or guardian and sometimes by the youth participant.
This packet contains the Camper Application Form, the Parent or Guardian Consent Form, the Code of Conduct Agreement and
Policy, the Contact Information Release Form, and the optional Partial Scholarship Request procedure.

Please double-check that all sections have been signed before submitting this application by May 7, 2010 to your local
county MSU Extension office 4-H staff. Be sure to include your deposit ($100 for 4-H’ers; $110 for those not currently
enrolled in 4-H) made payable to MSU Extension. Please note “4-H GLNR Camp” on the memo line. (Even if you are
applying for state 4-H partial scholarship support, you should still submit a deposit with your application unless your county
MSUE office has committed local scholarship support for the deposit.) Late applications will be accepted until June 11 with a
$25 late fee if space is still available.

County staff will forward your application to the State 4-H Office, Michigan State University, 160 Agriculture Hall, East Lansing,
Michigan 48824-1039 upon receipt. County MSU Extension offices will remit payment with one county check for their entire
camp delegation after camp enrollment is finalized.


Full Legal Name: ____________________________________________________ County: _________________
                  Last                         First                            M.I.

First Name as you’d like to be referred to (if different from above) ________________________________________
Phone: (_____)____________________ Email: ______________________________
Address: _____________________________________________________________________________________
                  Street Name/Number                    City                     State                 Zip Code
Sex: Male ___ Female ____              Age as of July 1, 2010: __________ Birth Date (mm/dd/yyyy): ______________

Expected Year of High School Graduation: ____________________________ U.S. Citizen? Yes ___ No ___
School name: __________________________________________ School city: ____________________________

4-H member: Yes ____No ____           Number of years in 4-H (Include current year): ____________________

Have you attended 4-H Great Lakes & Natural Resources Camp before? Yes ____                No ____
If yes, how many years did you previously attend? __________ List which years: ____________________________
How did you or your family FIRST learn about 4-H Great Lakes and Natural Resources Camp? (check one)
__A County MSU Extension office, 4-H Educator or Sea Grant Educator
__At school or from a teacher
__At an MSU-sponsored event/program
__4-H Leader
__Family member
__Past Camper of 4-H Great Lakes & Natural Resources Camp
__Staff member of 4-H Great Lakes & Natural Resources Camp
__Mailing or newsletter from County MSU Extension/4-H Office
__Camp web site
__An email message
__A conservation or environmental group
__Don’t know or can’t remember
__Other (please specify) ________________________________________________________________________
1. What previous camp experience have you had? List other camps you have attended and when:

2. Why do you want to attend 4-H Great Lakes & Natural Resources Camp?

3. What previous experience have you had in environmental science or natural resources projects and activities?

A variety of recreation learning options will be held Monday through Friday. At camp you’ll sign up for 4 or 5 recreation choices.
(First time campers will fillet the fish caught during charter fishing for one of these session time periods.) Offerings will vary each
day based on weather, equipment and camp staff availability.

Please rank your top six preferences below to help us gauge camper interest and adjust the daily offerings accordingly.
(You are not committing to these activities at this time, only indicating your preferences.)

___ Archery                                                        ___ Lighthouse tour
___ BB gun or air rifle shooting                                   ___ National marine sanctuary tour
___ Canoeing*                                                      ___ Orienteering
___ Crafts                                                         ___ Outdoor survival skills
___ Digital photography                                            ___ Quarry field trip (rocks and fossils)
___ Electrofishing                                                 ___ Sailing (for strong swimmers only)
___ Entomology (insects)                                           ___ Snorkeling (for strong swimmers only)
___ Fly-tying                                                      ___ Swimming enhancement (learn to swim)
___ Hiking                                                         ___ Video technology
___ Kayaking (for strong swimmers only)                            ___ Water color painting
___ Lamprey presentation (invasive specie)

* There must be at least one person who can swim in each canoe.

Adult T-Shirt Size
__Small (S)      __Medium (M)           __Large (L)           __Extra Large (XL)       __XXL         __XXXL

Residence Description
__Urban     __Suburban             __Rural, but not on a farm       __Farm

Racial-Ethnic Category (Optional):

Are you of Hispanic/Latino ethnicity? __Yes             __No

Select one or more of the following that best describes you:
__Black/African American
__American Indian/Alaskan Native
__Hawaiian/Pacific Islander
Applicant’s Name: __________________________________________                           County: ____________________________

SECTION 2 – PARENT OR GUARDIAN CONSENT FORM (Required for youth under age 18 to participate.)

I hereby grant permission for my child (print name) ___________________________________ to participate in all educational and social
activities at 4-H Great Lakes & Natural Resources Camp 2010, which is sponsored by 4-H Youth Development of MSU Extension.

I understand that area site visits are a key learning component of this camp and that my child will be transported as part of the group to
various sites by a minivan driven by a camp staff member. I have also read the camp activity descriptions and understand and accept any
risks associated with camp activities.

Parent/Guardian Name (please print)

________________________________________________________                                        ___________________
Signature of Parent/Guardian                                                                    Date


I have read and agree to abide by the code of conduct included on the last page of this application.

___________________________________________________                                             __________________
Signature of Participant                                                                        Date

I expect my child to abide by this code of conduct.

Signature of Parent/legal guardian for youth under age 18


Please check one choice below:

May we list your name and contact information on a participant list to be distributed in mid-July to all participants for car pooling purposes?
Yes _____ No _____

____________________________________________________                                            __________________
Signature of Parent/Guardian or counselor applicant age 18 & up                                 Date


A limited number of $50 scholarships are available to pay part of the camper fee for 4-H members who cannot attend camp without financial
assistance. (Preference will be given to first-time attendees.) Please check with your county MSU Extension office, your school or other
local organizations about other local scholarships that may be available to help you attend 4-H Great Lakes & Natural Resources Camp.

To apply for a state 4-H partial scholarship to attend 4-H Great Lakes & Natural Resources Camp, you must submit the following by
May 7, 2010:

1. The completed Camper Application Packet.
2. A letter of recommendation from your county MSU Extension 4-H staff member.
3. A letter requesting scholarship funds addressed to the “4-H Great Lakes Camp Director.” In the letter, be sure to include:
   a. Why you’d like to attend this camp.
   b. Your experience and/or leadership in natural resources and environmental education activities (if applicable).
        • Describe how you’d use your 4-H Great Lakes & Natural Resources Camp experience to benefit environmental programs in your
        • Tell us anything else you would like us to know about why you feel you qualify for a scholarship.
  c. If your family qualifies for free or reduced lunches at school and/or if your family qualifies for any other forms of state or federal support
      (food stamps, etc.)

If you are chosen as a state 4-H scholarship recipient, you will be notified when you are accepted to camp. The scholarship will be deducted
from your camp fee balance due in June.
CODE OF CONDUCT FORM – You may wish to keep a copy of this for your records.
Positive behavior is a key expectation for youth and adults participating in state-sponsored 4-H activities – behavior that reflects
trustworthiness, respect, responsibility, fairness, caring and citizenship. Participants are expected to fully participate, follow all
event guidelines and behave appropriately to ensure a high-quality learning experience and ensure the safety of all participants.
Youth and adult participants should be aware of the following:

          Theft, vandalism, the use of illegal drugs and alcohol, leaving the camp boundaries (except for session field trips
           arranged as part of the program under the supervision of staff) and other such offenses are strictly prohibited. Anyone
           involved with these offenses will immediately be sent home at his or her own expense and may be dismissed from
           MSU Extension 4-H Youth Development. Those engaged in illegal activities will be turned over to the proper
           authorities. Repair costs for damages incurred to property will be billed to those responsible.

          Participants may be sent home for inappropriate sexual behavior and behavior that violates the rights of others,
           particularly when the behavior is disrespectful as regards a person’s gender, race, age, sexual orientation, religion,
           national origin, disability or appearance. You may not tease, hurt or bully anyone, or use language, gestures or actions
           that will hurt others. Disciplinary action will vary based on the degree of the offense and will be determined by the 4-H
           staff in charge of the program.

          Youth participants are not permitted to use tobacco in any form.

          Housing areas are set up as all female and all male. Participants are not permitted in the housing areas assigned to
           members of the opposite sex (bathrooms, floors and rooms).

          All youth and adult participants are to wear their camp name badges around their necks at all times (except when
           sleeping, bathing and swimming, of course).

          Participants are responsible for their own belongings. Valuables, such as expensive jewelry and electronic devices,
           should be left at home. 4-H Youth Development is not responsible for any lost or missing items.

          Participants should dress casually, but neatly and appropriately, for the occasion. Shirt and shoes must be worn in
           eating areas.

All participants are expected to:

          Observe the 11:15 p.m. curfew. At 11:15 p.m. all participants must be in their assigned rooms for the night. Camp staff
           will do a room check each night at this time to account for each participant.

          Quiet hours are from 11:15 p.m. to 7 a.m. Everyone is to be in his or her own assigned room during these hours.
           (Exceptions apply for those needing to awake earlier for early bird activities such as charter fishing, Lake Esau or dock
           fishing, and polar bear swim).

          Camp staff is responsible for enforcing the rules as stated. Violators who are asked to leave will be sent home at their
           own expense. These rules are not subject to interpretation and each camper is expected to follow them without
           exception. Our primary consideration is to provide a safe, secure environment for all participants.

MSU is an affirmative-action, equal-opportunity employer. Michigan State University Extension programs and materials are open to all without regard to race,
color, national origin, gender, gender identity, religion, age, height, weight, disability, political beliefs, sexual orientation, marital status, family status or
veteran status. Issued in furtherance of MSU Extension work, acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture.
Thomas G. Coon, Director, MSU Extension, East Lansing, MI 48824. This information is for educational purposes only. Reference to commercial products or
trade names does not imply endorsement by MSU Extension or bias against those not mentioned. The name "4-H" and the emblem consisting of a four-leaf
clover with stem and the "H" on each leaflet are protected under Title 18 U.S.C. 707.

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