DUE:May 1,2017
One Application per camper
CARROLLCOUNTY4-H SHOTGUNCLINICAPPLICATIONFORM–
Youthages8-13, by Jan. 1, 2017
**In order to maintain safety the camp will be limited to 15participants**
UME is collecting informationin ordertoenrollyouin theUMEsponsoredCarrollCo. 4-HShotgunClinic.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:
SexofCamper:
RACE
Thisinformationisrequestedonanoptionalbasis. Yourcooperationinprovidingitisappreciated. Pleasechecktheboxthatindicatesyourrace whichwillbeusedonlyforreportingpurposes.
AmericanIndianBlack
Asian/PacificIslanderWhite
Hispanic
BirthDate: ______
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:
IsCamperaCarrollCo.4-Hmember? Gradecompletedatendofcurrentschoolyear:
When:July 10 & 11,2017(Monday & Tuesday)
Where: Dug Hill Rod & Gun Club, 4100 Wine Road,Westminster,MD
Who:Campersareyouthages8 thru13asofJanuary1,2017
Cost: Allcampers-$65– reg. form and deposit of $30due with application, paidinfullbyMay 1,2017
Time:8:00a.m.– 4:00p.m.--nolunchprovided(campersmustbringalunch-refrigerationavailable)
Makeyourcheckpayableto:CCEAC
MailApplicationandpaymentto: CarrollCountyExtensionOffice
Shooting Sports Camp
700AgricultureCenter
Westminster,MD21157
NOREFUNDSwillbemadeafterMay 1,2017unless theprogramis cancelledforlackofparticipation!
•Ifyouhaveadisabilitythatrequiresspecialassistanceforyourparticipation intheCarrollCounty4-H Shotgun Clinic,July 10 & 11, 2017,pleasecontact theCarrollCountyExtensionOfficeat410-386-2760or1-888-326-9645byMay 1, 2017.
•Inordertobetteraccommodateyourchild’sneeds,pleaselistanymedicalconcerns,disabilities,orspecialneedsofcamper.
•Pleaselistanyneededdietaryaccommodations,includingvegetarianism.
•Healthstatements,detailsonarrivaltime,whattobring,etc.,willbegiven out at Camp Orientation on June 1, 2017.
•RELEASE:I,theundersigned,inconsiderationofmychild’sparticipationinCarrollCounty4-H ShotgunClinicbeingconductedfromJuly 10 & 11,2017,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 foreducationalandpromotional purposeswithoutcompensation.
YouthSignature:
Date:
Parent/GuardianSignature
Date:
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, or national origin, marital status, geneticinformation, or political affiliation, or gender identity and expression.