Form

Iowa 4-H Center Winter Camp

Enjoy winter at the Iowa 4-H Center with two different camp opportunities.
Sign me up for:*

Winter Hullabaloo, Ages 8-13, $110 Winter Teen Scene, Ages 14-18, $60
Camper's Name*
Camper is*

Male Female
Camper's Age*
Birth Date*
Month Day Year
Parent's Name*

Address*

E-mail*
Cell Phone Number*
- Area Code Phone Number
Alternative Phone Number*
- Area Code Phone Number
Emergency Contact #1*
Emergency Contact Phone Number*
Emergency Contact #2*
Emergency Contact Phone Number*
Cabin mate Request (limit one)
Waiver/Release/Consent

My child has permission to attend the camp listed above and participate in all planned camp activities such as, but not limited to: snow tubing, sledding, ice skating, out-of-camp trips by van or bus, and hiking. I have read and understand the purposes and activities associated with the Iowa 4-H Center. I understand that if I cancel a camp program, the fee will not be refunded. I understand that in order to provide a safe and cooperative group experience, a child may be dismissed from the program for reasons including behavior, illness/injury, or homesickness. I will assume responsibility for transportation to and from the Iowa 4-H Center. I also grant permission to Iowa State University Extension to photograph my child for publicity purposes
I have read the above waiver/release/consent form and understand the terms*

Yes I agree
Parent/Guardian Electronic Signature*
Should be Empty:

Iowa 4-H Center Winter Camp