Jackson County Summer Camps
Camper Information
Camper's Name
*
First Name
Last Name
Grade Completed in May 2025
*
Please Select
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Special Health Considerations
Allergies, Conditions, Medications, etc. *If your child will need to take medication during this event, please contact our office for a request form.
Camper's Residence
Farm/Country
Small Town (Like Maquoketa)
Big Town (Like Dubuque)
Camper's Ethnicity
Non-Hispanic or Latino
Hispanic or Latino
Prefer not to say
Camper's Race
American Indian or Alaska Native Only
Asian Only
Black or African American Only
Native Hawaiian or Other Pacific Islander
White Only
Other or Combination of Races
Prefer not to say
Parent/Guardian Information
Parent/Guardian's Name
*
First Name
Last Name
Guardian's Email
*
example@example.com
Guardian's Phone Number
*
Please enter a valid phone number.
Emergency Contact Information
This information should be different than the Parent/Guardian's information above. We want at least 2 different points of contact in case of emergencies.
Emergency Contact's Name
*
First Name
Last Name
Relationship to Camper
*
Phone Number
*
Please enter a valid phone number.
Pick-Up Information
Who is allowed to pick up your camper after camp is finished? Please provide a name(s) and a phone number if not listed previously.
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
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Camp Selection
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Garden Adventures
Join us for a fun day of gardening activities! Get your hands dirty, explore nature, and create your own mini garden to take home.
$
30.00
Ocean Explorers Engineering & Coding 4-H LEGO Camp! (for 3-5)
Dive into a day of fun and learning where kids will explore the wonders of ocean exploration through hands-on STEAM activities. They'll design, build, and program LEGO® SPIKE™ creations while fostering teamwork and creativity. Don't miss out on this exciting 4-H adventure! For current 3rd - 5th graders!
$
30.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
ACH Bank Transfer
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Consents
I give permission for my child to have their photo taken to be used for news releases and reports.
*
Yes
No
If an injury or other medical condition occurs, I give permission to the program staff to provide routine health care and seek emergency treatment.
*
Yes
No
I give permission for my child to participate in the 4-H program and assume the risk of participating. I also agree to pick up my child if the program leaders do not feel my child is abiding by the behavior expectations.
I give permission for my child to participate in the 4-H program and assume the risk of participating. I also agree to pick up my child if the program leaders do not feel my child is abiding by the behavior expectations.
*
First Name
Last Name
To view the full registration/disclosure statements, visit our website.
Guardian Signature
Date
*
-
Month
-
Day
Year
Date
Guardian Name
*
First Name
Last Name
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