Camp Class Sign Up: You will receive a camp packet in the mail.

Complete the entire packet and return it as soon as possible. We will not accept incomplete packets. Classes will be assigned on a first-come first-served basis. We will do our best to place campers in the classes they prefer, but we cannot guarantee spots in any specific classes. The earlier your paperwork is completed the better chance you have of getting the classes you would like. Holiday Lake 4-H Educational Center Located only 14 miles northeast of the town of Appomattox, Holiday Lake 4-H Center is within easy driving of many Virginia cities including Richmond, Lynchburg, Roanoke, Charlottesville and Farmville. Outdoor recreational facilities include canoeing and/or fishing on 150 acre Holiday Lake three hiking trails. The Center also has available two rifle ranges along with an archery range and skeet field, volleyball court, softball field, Jr. Olympic swimming pool, and high and low-ropes course for building self-esteem and team cooperation. Some of the classes we offer include: ArcheryRiflery Performing Arts SwimmingNature/ForestryCanoeing FishingLeathercraftOutdoor Living Skills Challenge Course and much more.

2013 Lynchburg/ Appomattox 4-H Camp

We need 4-H Volunteers to attend Camp!!!

For more information to volunteer and about summer camp: Please contact at the following: Kevin Camm Extension Agent, 4-H Youth Development/ Agriculture & Natural Resources Lynchburg Extension Office 2348 Lakeside Drive P.O. Box 10364 Lynchburg, VA 24506 Phone: (434-455-3740 Fax: (434) 847-1682 Were on the web! http://offices.ext.vt.edu/lynchburg/ www.4-h.ext.vt.edu/ www.ext.vt.edu Like us on Facebook: www.facebook.com/LynchburgVCE Microsoft
Primary Business Address Return this form and deposit or full Your Address Line 2 to: Your Address Line payment 3 Your Address Line 4 Extension Office Lynchburg P.O. Box 10364 Lynchburg, VA 24506 Phone: 555-555-5555 Make checks payable to: Fax: 555-555-5555 E-mail: someone@example.com Treasurer, Virginia Tech.

August 59, 2013 Holiday Lake 4-H Education Center Appomattox, Va.

"If you are a person with a disability and desire any assistive devices, services or other accommodations to participate in this activity, please contact the Lynchburg Extension Office, (434) 455-3740 (TDD*) Organization during business hours of 8:00 a.m. and 4:30 p.m. to discuss accommodations 2 months prior to the event. *TDD number is (800) 828-1120."

*CAMP FILLS UP QUICKLY*

DO NOT DELAY!!

Who can go to Camp: Any boy or girl who are ages 9 13 as of September 30, 2013. Trained Teen Counselors who are 14 as of January 1, 2013 may go at a reduced fee. Trained Adult Counselors go free! Registration Deadline: Return the attached registration form with a $100.00 deposit or full payment ($190.00) by June 14. This will reserve your space at camp. Options include payment in full, monthly payments and applying for scholarship. All forms and payment in full must be complete by June 14. There will be a $35 additional fee on all returned checks. Cancellations must be made on or before June 14, 2013. Cancellations after this date will only receive a refund of 1/2 the camp fee. All fees are non-refundable after July 12, 2013. Camp Fees: The total cost per child is $190 and includes all expenses with the exception of souvenirs and snacks. The fee covers overnight lodging, meals, insurance, counselor and adult supervision, classes, program costs, camp tee shirt, and transportation to and from camp. Payment Schedule $100 due upon registration $45 due June 1 $45 due July 1 Total payment of $190 due July 12 All fees must be paid by June 1 or your child may not be able to attend camp. A limited number of partial scholarships available. A late fee of $25 will be charged if final payment AND forms are not received by July 12.

Campers Name: _______________________________________________________ Mailing Address :

where all camp correspondence should be sent

_________________

City:___________________________ State _______________ Zip:_____________ Male ____ Female____ Birth date:_______________ Camper Age: (as of 9/30/13) _____ T-Shirt Size_________ - Adult Sizes Only 1. 2. 3. 4. Race (circle all that apply): White Black Asian American Indian Alaskan Native Ethnicity (circle one): Hispanic or Latino Not Hispanic or Latino Did you attend 4-H Camp last year? Yes No Grade in School: ____ Name of School: __________________________________ Parent/Adult Contact Info Home Phone Work Phone Cell Phone Email Is this the primary contact person? ___ Yes ___ No ___ Yes ___ No Parent/Guardian 1 Parent/Guardian 2

Name :_____________________ Name :__________________

What is the best way we can contact a parent between 8:00 a.m.- 4:30 p.m.:

Home

Work

Cell

Email

** ____ Check here if you would like an application for a need-based scholarship.
If checked, a separate scholarship form will be mailed to you. You must return the completed form with camp deposit to the Extension Office by June 7, 2013. NOTE: A minimum deposit of $100.00 will be required before the scholarship application can be reviewed. A limited number of partial scholarships are available not to exceed $75.00.

FOR OFFICE USE ONLY Cash Check# ________________ Date Received: _______________ Rct.# ____________ By: _________ Deposit Payment Amount: : Other: ___________

$100 Deposit $190 Payment in Full

Forms Sent: __________________