Mendocino Lake 4-H Camp Registration 2025 - Jr. Staff Application

REGISTRATION DEADLINE May 9, 2025

June 23-27, 2025 - Mendocino Woodlands Camp

4-H Members 12 and 13 years of age as of December 31, 2024 are eligible to be Jr. Staff but are not required. If you prefer to go as a camper please fill out the camper application instead.

There will be two meetings covering leadership and specific duties at camp.
Jr. Staff will be notified of meeting dates and are encouraged to attend both.

Registration fee is $250 per youth. $100 down to hold your spot; registration fee is due May 9, 2025.

Payments are welcome and some scholarships are available. NO REFUNDS AFTER May 9th!

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

Jr. Staff Information

Jr. Staff First Name: ✻

Jr. Staff Last Name: ✻

Gender ✻

Male Female

4-H Club or Unit ✻

Age (as of 12/31/2024) ✻

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

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 at the link below and agree to follow it.
https://ucanr.edu/sites/uclakecounty/files/404209.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 9, 2025

NO REFUNDS WILL BE ISSUED AFTER May 9th!

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