Lincoln County 4-H/FFA Ag Camp Registration
Camp Dates: July 6th/8th/10th Time: 8:00 am to 12:00 pm Ages: 8-11 Location: Lincoln Civic Center
Camp Fee: $50.00
A camp shirt along with all activities and snacks are provided. Payment is due with submission of entry form. Deadline to register is June 1st.
Participant's Full Name
*
First Name
Last Name
Participant's Date of Birth
*
-
Month
-
Day
Year
Date
Age:
*
Shirt Size
*
Youth Small
Youth Medium
Youth Large
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does the participant have any allergies or medical conditions?
*
Additional Notes or Questions
Payment:
Payment can be submitted by mailing a check to Enterprise FFA OR paying via PayPal. For payment via check: Enterprise FFA 2645 Nola Rd. NE Brookhaven, MS 39601 For PayPal: Send to mgoldman416@yahoo.com Registration will not be considered complete until payment has been received- if you mail a check, you will get a text confirmation once your check has been received.
Payment options:
I will submit payment via PayPal
I will submit payment via mailed check.
Liability Form: I understand the student will be under supervision from the Lincoln County 4-H/FFA Agents and Advisors; however, the MSU Extension service, the schools, the Lincoln Civic Center and those in charge will not be held responsible in case of an accident. Signature:
Photograph Release: I permit Mississippi State University Extension Service to photograph my child and/or me and use those photographs for educational and publicity purposes. I release Mississippi State University and the Mississippi State University Extension Service from any claims that might arise from use of these photographs. Signature:
For more information, contact:
Jennifer Williams- 601.757.8470 Mollie Goldman- 601.669.0240 Courtney Myers- 601.757.7911 Haley Britt- 601.835.8031
Register
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