2022 Grange Camp Registration

July 10-16, Eastern 4-H Center (transportation provided)

Please complete one form for each camper. Following the submission of this online form you will receive an email, at the address you provide, with a link to the camp health forms. Please complete the health forms and submit them with a physical to jenniegentry@ncgrange.com. Details for completing the health form are included in the link.

Optional bus transportation is provided to and from camp, which you can sign up for below.

The camper's reservation is not complete until all forms are received.

Camper Name *

First Name Last Name

At the time of camp this child will be *

Junior (6-13)/Grades K-8th) Youth (14-20 / 9th grade-college)

Gender *

Male Female

Birth date *

Month Day Year

Age at camp *

Grade level this fall *

Camper E-mail

Camper Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Camper Cell Phone

Area Code Phone Number

Camper shirt size *

Child small Child Medium Child Large Adult Small Adult Medium Adult Large Adult X-Large Adult XX-Large

Grange (if a member)

Guardian's Name *

First Name Last Name

Guardian's E-mail *

Guardian's Cell Phone *

Area Code Phone Number

Guardian Home Phone

Area Code Phone Number

Other emergency contact *

First Name Last Name

Other emergency contact phone *

Area Code Phone Number

Any special requests?

Camper will ride the bus to and from camp *

Yes No

Which stop will they get on & off?

Statesville Winston Salem Hillsborough Raleigh Rocky Mount

I give my child permission to ride the charter buses that Grange provides to and from camp.

Signature (use your finger or mouse to sign)

Clear

PROGRAM AGREEMENT:

Please read carefully. Each camper and his or her parent / guardian must sign before attending camp.

I understand that my participation in the Grange Camp program is voluntary. During all activities, I will choose my level of participation. I understand that the Grange Staff consists of volunteers. I understand that the 4H staff is trained to work with and protect the physical safety of each camper in all activities and that staff will be present in all activities. I understand there are certain risks in participating and I elect to participate regardless of these risks. Therefore, I assume all responsibility in the event of injury and release the NC State Grange, its staff and counselors from all liability, damages, costs and expenses arising out of injury, loss of life or damage to personal property that may occur as a result of participating in this program.

Camper Signature (use finger or mouse to sign)

Clear

Guardian Signature (use finger or mouse to sign)

Clear

CONSENT AND RELEASE:

I grant the NC State Grange the right to use and / or distribute photographs and video footage of my child for promotional use only. I understand that pictures from Grange Camp are used to promote its Youth and Junior Programs via newspaper, website, brochures, social media, newsletter, etc.. I give my consent to the NC State Grange to use such items for promotional purposes only, including press releases to local newspapers on awards my child may receive at camp.

Parent / Guardian Signature

Camper Signature if 18 or older

Camper/Guardian Signature (use finger or mouse to sign)

Clear

PLEASE READ PRIOR TO SELECTING YOUR PAYMENT BELOW!

Paying Online: If you choose to pay online, please only select ONE payment option from the menu below. After clicking "submit," you will be immediately redirected to PayPal to make your Grange Camp payment. You do not have to have a PayPal account to use this feature. Simply click the link to pay with a debit or credit card.

Payment Options: To ensure that your registration goes through, please only select ONE payment option.

· If you are a current Grange member, please select the first option: Member Rate.

· If you are a first year camper, please select the second option: First Year Camper. (A camper can attend their first time without being a member.)

· If you have attended camp previously and are NOT a member, please select the third option: 2nd Year Non-member Camper. (This pays your $20 dues and your camp fee. Campers are required to be members after their first year.)

· If you prefer to pay with a check instead of paying online, please select the fourth option: Pay By Check. (You may mail your check to: NC Grange, 1734 Wilkesboro Hwy, Statesville, NC 28625). Please make payments by July 1.

· If your Grange is paying for you to attend camp, please select option five: My Grange is Paying.

· If you would like to make a partial payment online, please select the last option, Other, and fill in the box with the amount you will be paying online. A PayPal invoice will be emailed to you for the amount. The total camp fee must be paid by July 1.

We look forward to receiving your camp registration. Please note that if you do not receive an automatic confirmation email with the health form link, then your camp registration did not go through. If this happens, please re-register or contact jenniegentry@ncgrange.com with any questions. Thank you!

My Products *

Member Rate (must be a current member) $ 300.00

First Year Camper (non-member) $ 300.00

2nd Year Non-member Camper $ 320.00

Pay by check Free

My Grange is paying Free

Youth Team/Ambassador Free

Other Free

If you would like to make a partial payment online, please select "other" above and fill in the amount here. We will email you an online invoice for the amount.