Mendocino Lake 4-H Camp Registration 2024 - Camper & Jr. Staff Application

REGISTRATION DEADLINE May 10, 2024

Mendocino Lake 4-H Camp is open to 4-H members 9 - 13 years of age as of December 31, 2023. 4-H members 12 and 13 years of age are eligible to be a Jr. Staff. Registration fee is $250 per youth. $100 down to hold your spot; registration fee is due May 10, 2024; Payments are welcome and some scholarships are available. NO REFUNDS AFTER May 10th! Space is limited - registrations are accepted on a first come basis.

If you have questions please contact the UCCE office at 263-6838 or Jean Goulart at jgoulart@ucanr.edu

✻ = Required

Camper Information

Camper's First Name: ✻

Camper's 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

I am a first time overnight camper. ✻

Yes No

4-H members 12 -13 years of age are eligible to be a Jr. Staff. Jr. Staff will have the opportunity to help counselors during flagepole, meals, activities and dining hall duties.

I would like to be a Jr. Staff ✻

Yes No

As a Jr. Staff I would like to help in the following areas.

Evening Activities Campfire Workshops Afternoon Activities Kitchen/Dining Hall Last Night Celebration (Social)

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 it.
https://ucanr.edu/sites/uclakecounty/files/364263.pdf ✻

Yes No

Participants will be considered registered once the following has been received by the Lake County UCCE Office:

Registration is completed online or a paper packet has been submitted.
$250 registration fee paid by May 10, 2024

NO REFUNDS WILL BE ISSUED AFTER May 10th!

Would you like to pay the $250.00 registration fee by credit card:

$250.00

Will you pay by check or cash?

Check Cash

Please make checks payable to: 4-H Summer Camp

Mail to: Mendocino-Lake 4-H Summer Camp
883 Lakeport Blvd., Lakeport CA 95453