DUE:June8,2017

ONEAPPLICATIONPERCHILD

CARROLLCOUNTY4-HCLOVERFUN DAYSAPPLICATIONFORM–Youthages5–7

Week 1 – July 11-13, 2018

**InordertooperatetheCloverFun Daysprogram,werequireaminimumof12participants.

Families willbenotifiedifwemustcancelthesessionforlack ofparticipation.**

UME is collecting informationin ordertoenrollyouin theUMEsponsoredCarrollCo. 4-HClover Fun Days.Ifyoudo not providethe requestedinformation,yourchildmaynotbeableto attendnorreceivefurtherinformation.Theinformationyouprovidemaybe sharedwithUMEandshort-termappointed volunteersorinstructors.Informationprovidedto UME mayalsobesharedamong officeswithintheUniversityand withintheUniversitySystemofMarylandand outsideentities asnecessaryorappropriatein the conductoflegitimateUniversitybusinessand consistent withapplicablelaw.BecausetheUniversityis aStateeducational institution,suchinformationmayalsobesubjectto disclosureundertheMDAccessto PublicRecords Act.Individualsmayinspect and/orcorrecttheirpersonalinformationasprovidedbythe“PublicRecords Act”and/orotherapplicablelaworUniversitypolicy.

Name: Address:

SexofYouth: Birth Date: ______

RACEDATA

Thisinformationisrequestedonanoptionalbasis. Yourcooperationinprovidingitisappreciated. Pleasechecktheboxthatindicatesyourrace whichwillbeusedonlyforreportingpurposes.

AmericanIndianBlack

Asian/PacificIslanderWhite

Hispanic

Email Address: ______

HomePhoneNo.:

Residence(chooseone):

A–onafarm;

B–Ruralarea/townof 10,000orless

CellPhoneNo.:

C–Town/cityof 10,000-50,000;

D–Suburbof cityover50,000;

Parent/GuardianPhoneNo.(Work):

E–Cityover50,000

Parent/GuardianName:

IsYouthaCarrollCo.4-Hmember?: Gradecompletedatendofcurrentschoolyear:

When:July11 - 13, 2018(Wednesday– Friday)

Where:University of Maryland Extension, CarrollCountyOffice,Westminster,MD

Who: Youthages5 thru7asofJanuary1,2018

CostAndDeadlines:Allyouth-$75– paidinfullbyJune8,2018

Time: 8:30a.m.– 4:00p.m.--nolunchprovided(participantsmustbringalunch-refrigerationavailable)

Makeyourcheckpayableto:CCEAC

MailApplicationandpaymentto:CarrollCountyExtensionOffice(4-H Clover Fun Days)

700AgricultureCenter

Westminster,MD21157

Refunds:NOREFUNDSwillbemadeafterJune8,2018unless theprogramis cancelledforlackof

participation!

Scholarships:Checkherefor moreinformation.Partialscholarshipsareavailablefor participantsin

need of financial assistance.

•Ifyour child hasadisabilitythatrequiresspecialassistancein order toparticipate intheCarrollCounty4-H Clover Fun Days,July11-13, 2018pleasecontact theCarrollCountyExtensionOfficeat410-386-2760or1-888-326-9645byJune8, 2018.

•Inordertobetteraccommodateyourchild’sneeds,pleaselistanymedicalconcerns,disabilities,orspecialneedsofparticipant.

•Pleaselistanyneededdietaryaccommodations,includingvegetarianism.

•Healthstatements,detailsonarrivaltime,whattobring,etc.,willbemailedafterJune8,2018.

•RELEASE:I,theundersigned,inconsiderationofmychild’sparticipationinCarrollCounty4-H Clover Fun DaysbeingconductedfromJuly11– July13,2018,doherebyrelease,discharge,and foreverholdharmless,UniversityofMarylandExtension,allitsemployees,volunteers,and supportersthereofinconnectionwiththeaforementionedprogram,fromanyandallclaims, demands,damages,actions,liability,orsuitsatlaworinequity,forpersonalinjury,whether physicalormental,propertydamage,medical,dentalorhospitalexpensesoranyotherexpenses ofwhateverkind,includingdeath,whichImayhavehad,nowhave,ormayhereafterhave,inany mannerconnectedwith,arisingfromorgrowingoutofmyparticipationinsaidprogram.

I,theundersigned,acknowledgethatIsignthisReleaseknowinglyandintelligentlyandwithfull andcompleteknowledgeof thepurposeofsaidprogramandwithoutanyformofduressand/or intimidationwhatsoeveronthepartof theUniversityofMarylandExtensionprogram.

Parent/GuardianSignature Date

•IgivepermissiontotheCollegeofAgricultureandNaturalResources,UniversityofMD,touseand publishmyphotograph foreducationalandpromotionalpurposeswithoutcompensation.

YouthSignature:

Date:

Parent/GuardianSignature

Date:

The University of Maryland Extension programs are open to all and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, national origin, marital status, genetic information, political affiliation, and gender identity or expression.