2013 Counselor College Canter’s Cave 4-H Camp March 16-17

1. EMPOWERMENT THROUGH EDUCATION • 2013 Counselor College • Canter’s Cave 4-H Camp • March 16-17 Check in is March 16, 12:45 PM with Registration until 1:30 PM Please bring bedding, towels and toiletries, outdoor clothing, comfortable shoes, and your counselor handbook (if this is your first year to Counselor College you will receive your hand book at registration.). Counselor College is open to any teen 14 -18 who would like to be a camp counselor. Sessions are based on your years of experience as a camp counselor. Class registration will consist of some require sessions along with some electives that you choose! This way you get to learn what you need and what you want. All sessions are interactive and most are hands on. Come ready to participate, learn and have fun! One other BIG PLUS to Counselor College is you get to meet new friends from all over Ohio! To register please complete the back of this form and return it with payment to the Gallia Co. Extension office by March 1st. Cost is $40.00 Registrations are due to Gallia County Extension Office by March 1st a late fee of $5.00 will be added after that date. If you would like a CCU counselor shirt please be sure to include $10.00 with your registration. ($12 for all sizes above XL) All new participants will receive a CCU counselor handbook, returning counselors will receive new handouts and updates for their handbook. Check out Canter’s Cave Camp www.canterscave4hcamp.com

2. Join us at CCU- Canter’s Cave University “Counselor College” Est. 2008 Name___________________________________ County____________ Address___________________________________________________________ City_____________ Zip_______ Phone_____________ E-mail address ____________________ Cell Number ______________________ Age:_____ Gender: M F Parent/Guardian Name________________ Emergency Contact Name & Number_____________________________________ Number of years you have been a counselor_________ Have your been to CCU before __Yes or __No Would you like a Counselor Shirt? (cost $10.00 for S-L $12 for XL, sizes) ______ yes ______no Shirt size small medium Large X Large 2XLG 3XLG (Please circle size needed) Shirt colors 1st yr. counselor - Green, 2nd yr. Blue 3rd yr. Red 4th yr. Orange (please circle color) Any special dietary needs or food allergies? _____________________________________ Do you have any health related concerns we should know about_______________________ I understand that this is a 4-H event and agree that I will act in a responsible manner as a 4-H member. I will obey the rules set fourth by OSU Extension Personnel, adult volunteers and Canter’s Cave Camp staff in attendance. Any violation of the rules including disruptive behavior, lack of respect for other members or adults, possession of alcohol, tobacco products, or possession of a weapon will be reason for me to be dismissed from the camp and dismissal of being a camp counselor. _______________________________________________________ Member’s signature Date I understand that my child’s participation in this event is a privilege and not a right. I understand that my child must abide by the rules and regulations of OSU Extension and Canter’s Cave 4-H Camp, Inc. or I, as parent/guardian, will assume responsibility of the child being sent home. ____________________________________ ___________________ Parent’s signature Date I have completed the Canter’s Cave Health Release Form please check yes _____ I have completed the Canter’s Cave Activity Release Form please check yes _____ I have enclosed my registration Payment & optional shirt payment please check yes _____ Please make all checks payable to the Canter’s Cave 4-H camp We gratefully acknowledge the continued help and financial support of our local county commissioners. We appreciate their input and participation in our programming efforts. Ohio State University Extension embraces human diversity and is committed to ensuring that all research and related educational programs are available to clientele on a nondiscriminatory basis without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity or expression, disability, or veteran status. This statement is in accordance with United States Civil Rights Laws and the USDA. Keith L. Smith, Ph.D., Associate Vice President for Agricultural Administration and Director, Ohio State University Extension TDD No. 800-589-8292 (Ohio only) or 614-292-1868