Wilderness Wonder's Explorer Camp

Wilderness Wonders Camp REGISTRATION FORM
Camp Norwesca, Chadron, NE June 2-3, 2017
Please return registration form with $75 fee (payable to UNL Extension) AND Nebraska 4-H Participant Permission and Health Form by May 24, 2017, to:
Nebraska Extension Dawes County, 250 Main Street, Suite 8, Chadron, NE 69337

Contact: DAWES COUNTY: SHERIDAN COUNTY:
SIOUX COUNTY:

Leah Gremm, Extension Educator at (308) 432-3373 Terri Lemmon, Extension Assistant at (308) 432-3373 Melissa Mracek, Extension Assistant at (308) 327-2312 Jeanna Boland, Extension Assistant at (308) 668-2428

Please Circle: Male / Female
Name: _____________________________________________________________________________________ Age before January 1, 2017 ___________ Grade Level for Fall 2017__________

Mailing Address:
Email Address: Telephone Number:

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Fees: - $75.00 - Paid camper fees include all activities, insurance, meals, and lodging. PLEASE NOTE: There will be a $5.00 handling charge for all refunds
Allergies: ___________________________________________________________________________________ ___________________________________________________________________________________________ Medications:________________________________________________________________________________

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ALL PARENTS/GUARDIANS MUST READ, COMPLETE AND SIGN THE FOLLOWING:
Nebraska Extension, Camp Norwesca, or any other associate involved will not be responsible for any accident, injury, or loss to campers. The camper agrees to indemnify the camp and any sponsor against any claim or liability for damages caused by her/him.
I give permission to use my child’s name/photograph in publications, ads, news articles, videos, website, or other electronic media pertaining to 4-H.
________________________________ ________________________________________
Camper Signature Parent/Guardian Signature
Nebraska Extension is a Division of the Institute of Agriculture and Natural Resources at the University of Nebraska–Lincoln cooperating with the Counties and the United Sates Department of Agriculture.
Nebraska Extension educational programs abide with the nondiscrimination policies of the University of Nebraska– Lincoln and the United States Department of Agriculture.
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