Mendocino Lake 4-H Camp Registration 2024

✻ = Required

Teen Staff Information

First Name: ✻

Last Name: ✻

Gender ✻

Male Female

4-H Club or Unit ✻

Age (as of 12/31/2023) ✻

Mailing Address (Street address or P. O. Box) ✻

City: ✻

Zip code: ✻

Cell Phone Number: ✻

Second Phone Number: ✻

Email: ✻

T-Shirt included with registration: ✻

Youth sizes small Youth size medium Youth size large Adult size small Adult size medium Adult size large Adult size X large Adult size XX large Adult size XXX large

Dietary Restrictions (Please explain).

Parent/Guardian Emergency Contact Information

Name ✻

Relationship ✻

Mailing Address ✻

City/Town ✻

Preferred Phone Number ✻

Email address ✻

Second Adult Emergency Contact Information

Name ✻

Relationship ✻

Mailing Address ✻

City/Town ✻

Preferred Phone Number ✻

Email ✻

I have read the camp code of conduct and agree to abide to it.
https://ucanr.edu/sites/uclakecounty/files/390019.pdf ✻

Yes No

Number of years as a Camper ✻

Number of Years as a Teen Saff ✻

Teen Staff requirements 1 - 5:

1) 14 years of age by December 31, 2023

2) Currently enrolled in the 4-H program

3) Abide by and enforce the 4-H camp policy, mission, and code of conduct

4) Complete minimum of 14 hours of training - DATES TBA

5) Attend the entire camp session

Dean and Directors must meet requirements 2-9

6) Be 16 years old by December 31, 2023

7) Have attended 4-H Camp in the past

8) Have served as a Teen Staff or Dean

9) Attend additional planning meetings and trainings

Please mark all positions you are interested in applying for:

Director or Dean: Assist with camp planning and teen staff training meetings, co-coordinate camp with Executive Director, Teen Staff Coordinator and UC staff. Additional meetings and a higher level of time commitment is required. ✻

Yes No

Teen Staff (including line and cabin positions): Responsible for the campers' safety and being a positive role model, Overseeing the cabin area and keeping campers on schedule. Assist campers with cabin activities, chores and at bed time. Work with a group of campers during dining hall, activities, and flagpole ✻

Yes No

Teen Staff Activity Coordinator: Responsible for organizing, setup and overseeing a specific area, program or activity. For Example: arts and crafts, sports, woodworking, dancing, special projects, campfire, evening activities, dining hall. etc. May require additional meetings or trainings. ✻

Yes No

I am certified in:

CPR First Aid Lifeguard Other

Required Essay (100 words minimum)

Topic – Introduce yourself, share why you would like to be a part of summer camp, and what qualities you bring to the camp staff team. ✻

All Teen Staff - $200.00 fee is Payable to: 4-H Summer Camp. $50 installments may be paid between March through May. Final Payment due May 10, 2024. - NO REFUNDS AFTER May 10th!

To pay by check:

Make Payable to: 4-H Summer Camp

Mail to: Summer Camp c/o UCCE Lake

883 Lakeport Blvd., Lakeport CA 95453

Will you pay by check or cash?

Check Cash

Pay the $200.00 Camp Fee by Credit Card.

$200.00

Mendocino Lake 4-H Camp Registration 2024 - Teen Staff Application -