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(8/1) Outdoor Adventures Day Camp Form
August 1 9am-3pm, Pinicon Ridge, Central City
17
Questions
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1
Participant Name
*
This field is required.
First Name
Last Name
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2
Grade as of 01/01/2024
*
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3rd
4th
5th
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3
Birthday of participant
*
This field is required.
-
Date
Month
Day
Year
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4
Please list any allergies of participant. (if none put N/A)
*
This field is required.
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5
This youth has participated in Linn County 4-H this year.
*
This field is required.
This includes previous day camps, clubs, Lego League, and other 4-H events.
Yes
No
Unsure
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6
Gender identity of participant
*
This field is required.
Female
Male
Non-Binary
Prefer not to answer
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7
Participant is Hispanic/Latino
*
This field is required.
Yes
No
Prefer not to answer
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8
Please indicate race of participant
*
This field is required.
White
Black or African
Native Hawaiian/ other Pacific Islander
Asian
American Indian or Alaskan Native
Other Combination of Races
Prefer not to answer
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9
Where does participant live?
*
This field is required.
Cedar Rapids - City Marion - Suburb Hiawatha - Suburb
Please Select
Farm
Rural(under 10,000)
Town(10,000-50,000)
Suburb(Less than 50,000)
City(Greater than 50,000)
Prefer not to answer
Please Select
Please Select
Farm
Rural(under 10,000)
Town(10,000-50,000)
Suburb(Less than 50,000)
City(Greater than 50,000)
Prefer not to answer
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10
Caregiver Name
*
This field is required.
First Name
Last Name
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11
Caregiver Email
*
This field is required.
We will use this to contact you about camps.
example@example.com
Confirm Email
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12
Caregiver Phone Number
*
This field is required.
Please enter a valid phone number.
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13
Emergency Contact Information
*
This field is required.
Other than previous caregiver
First
Last
Please enter your phone
Please enter your email
Relationship to participant
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14
*I give permission for my child to participate in the 4-H program and assume the risk of participating. *I agree to the behavioral expectations of the 4-H program *If an injury or other medical condition occurs, I give permission to the program staff to provide care and seek emergency treatment.
*
This field is required.
visit our website to view full registration/ disclosure agreements: https://www.extension.iastate.edu/linn/summer-programs
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15
I give permission for my child to have their photo taken to be used for media, news releases, and reports
vist our website to view full registration/ disclosure agreements: https://www.extension.iastate.edu/linn/summer-programs
YES
NO
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16
My Products
*
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My Bag
1
My Bag
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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ORDER SUMMARY
Total cost
USD
Day Camp
$
30.00
+
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First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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17
Other comments?
This institution is an equal opportunity provider. For the full non-discrimination statement or accommodation inquiries, go to
www.extension.iastate.edu/diversity/ext
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