4-H Member Campership Application
Applicant must be a 4-H member, on current enrollment sheet and on file in the office.

NAME:_________________________________________________ AGE:_______________

DOB:________________ GENDER: M ____ F ____

ADDRESS: _____________________________________________________

CITY / STATE / ZIP:_____________________________________

MAILING ADDRESS (if different from above)

______________________________________________________________________________

HOME PHONE:______________________________

EMERGENCY (1)____________________________ (2)______________________________

 I am applying to:

Camp Marshall _____ Horse Camp _____ Horse Lover Camp _____
Week Number(s)_______________________

I have been a 4-H member for ____ years.

Name of 4-H Club___________________________________________

In the last 12 months I have:

    ___Baked good for advisory council auction (1 point)

    ___Brought items to the advisory council auction (1 point)

    ___Solicited items from a local business to the 4-H advisory council auction (3 points)
                           List name of business _________________________________________________

    ___Participated in evening of giving (5 points)

    ___Promoted 4-H to the public __________________________________(how) (1 point per event)

    ___Submitted 4-H records (5 points)

    ___Helped at a 4-H function ____________________________________(what) (2 points)

    ___Participated in 4-H program _________________________________ (1 point per event)

    ___Participated in 4-H community service project ________________________(1 point)

    ___Are you attending any other camps this summer? ______________________(name of camp)

We support this application and believe the information to be correct. If any tuition balance remains after campership is applied, parent / guardian will be responsible for balance owed. To be paid in full no later than the registration day of the week of camp you plan to attend.


___________________________________________________
(Applicant’s Signature)


___________________________________________________
(Parent / Guardian Signature)

 ____________________________________________
(4-H Leader Signature)

    Be sure to attach:
    1. A story from you "Why I want to go to 4-H Camp" (50 words)
    2. A statement of financial need from your parent, guardian, teacher, 4-H leader, clergy, etc.
    3. Must be in on or before April 1, 2005
    4. Mail to:

        Worcester County 4-H Center, Inc.
        92 McCormick Road
        Spencer, MA 01562
        ATTN: Executive Director