2011 Southern Region 4-H Volunteer Forum
October 6-9, 2011
North Carolina Delegate Registration Form
Staff Type Volunteer Paid Extension Employee
Last Name ______First Name ______
County ______District ______
Address ______
City ______State ______Zip ______
Phone (___)______Cell (____)______FAX ( ____) ______
Gender Male Female Race/Ethnicity ______
Is this your first visit to the SRVF? Yes No
Shirt Size (Adult S, M, L, XL, 2X-L, 3-XL) ______(Note: Shirt included in registration fee)
Emergency Contact Name & Phone Number
Housing at the CA Vines 4-H Center is hotel style rooms with 3 to 6 beds in each room. A limited amount of “married” housing may be available, but we cannot guarantee this space. The private space must first be utilized for those with special needs and any remaining rooms will be assigned to married couples. If you have special housing needs, please note below or you may contact Harriett Edwards (919.515.9548 or ). List below any specific individuals with whom you wish to be housed. Rooming assignments are made prior to arrival at the Center. Every effort will be made to accommodate your wishes.
______
______
Do you smoke? Yes No
Note that facilities are non-smoking, but due to allergies and other medical situations of some participants, we try to arrange housing so that non-smokers are together.
Transportation
Do you plan to drive to Rock Eagle? Yes No
▪ If yes, will you be driving your personal car or a county/state car or van?
▪ Could you provide transportation for additional volunteers from your district?
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Transportation (Continued)
In an effort to assist with the increased cost of transportation, we have arranged to have several counties drive state or county vans with the agreement that they will transport a minimum of 6 registered participants, each paying a $75 transportation stipend to help with the cost of gasoline. In return, the driver of the vehicle will receive a scholarship to attend the SRVF event. If your county is interested in providing a van to assist, please contact Harriett Edwards at the State 4-H Office for details. If you are going to be driving your personal vehicle or riding with someone who is driving a personal vehicle, the $75 transportation stipend will not be collected since you will be working with these individuals on a personal basis to fairly divide the costs of transportation. Participants will be responsible for any meals or other personal travel expenses.
Payment must be received on or before September 19, 2011, or may accompany registration forms with checks made payable to “NC 4-H Club Account.” Forms and payment should be forwarded to:
Southern Region 4-H Volunteer Forum
Attn: Harriett Edwards
NCSU Box 7606
Raleigh, NC 27695-7606
Event Options
Full Time Delegate Traveling in Personal Vehicle $255.00
Full Time Delegate Traveling in County/State Vehicle $330.00
After 09/01/2011 Full Time Traveling in Personal Vehicle $305.00
After 09/01/2011 Full Time Traveling in County/State Vehicle $380.00
This section is only for those who plan to arrive at Rock Eagle prior to Thursday afternoon’s official event start. Note that we encourage individuals to arrive on Thursday, but for those with travel issues, we will work with you based upon your selection of appropriate early arrival options and payment for this privilege. Note that Wednesday evening housing may be for one night only with final housing assignments available on Thursday.
Early Arrival on Wednesday for Dinner *MUST PRESENT MEAL TICKET $ 9.50
Early Arrival on Wednesday for Lodging $ 30.00
Early Arrival on Thursday for Breakfast *MUST PRESENT MEAL TICKET $ 7.00
Early Arrival on Thursday for Lunch *MUST PRESENT MEAL TICKET $ 8.00
Grand Total of Fees $______
Notes: Only those individuals who have registered for early arrival will be permitted entrance prior to Thursday afternoon. If you plan to arrive anytime prior to Thursday afternoon, you must register for early arrival.
Only those early arrival individuals who have a meal ticket will be permitted to eat in the cafeteria for any meal before Thursday dinner.
If full payment is not received on or before September 19, registration is subject to cancellation. In order to cancel participation in the Forum, cancellations made between September 1 and September 19 are subject to $50 administrative fees. Registrations cancelled after September 19 are non-refundable unless special exceptions are granted by the regional planning committee following request of the state coordinator.