4-H SUMMER CAMP
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2022
R
OBERT
P
.
A
MMAN
M
EMORIAL
C
AMPERSHIP
ONLINE A
PPLICATION
If you wish to be considered for a campership to send your child to 4-H Summer Camp at Camp Seeley in Crestline, CA, please fill in this form
COMPLETELY
and send to Dennis DeYoung / 9401 Reseda Blvd.,/ Northridge, CA 91324-2973. Applications must be postmarked or emailed
NO LATER THAN Friday, May 1st, 2022
. You can also scan and email to:
[email protected]
. You must have already submitted to the LA County 4-H Office a Registration Form, Medical Release Form and paid the nonrefundable deposit of
$75.00
.
More information about 4-H Summer Camp and forms available on the web at
www.4hsummercamp.com
Failure to complete this form accurately, legibly and completely may delay or negate your request
All information will be kept confidential.
*
Indicates required field
Camper's Name
*
First
Last
Camper's Age
*
Grade (entering in 9/2022)
*
Camp Program Name (Please type in 4-H Summer Camp)
*
Is Camper/Staffer currently enrolled in 4-H ? Select One
*
Yes
No
Is Camp Participant currently a staff member for the 2022 Camp ? Select One
*
Yes
No
Has the Camper/Staffer previously received a Campership from the R.P. Amman Memorial Campership ? Select One
*
Yes
No
Parent/Guardian’s Name
*
First
Last
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Parent/Guardian Email Address
*
County (Select One)
*
Imperial County
Los Angeles County
Orange County
Riverside County
San Barbara County
San Bernardino County
San Diego County
Ventura County
Other
If you checked other for your County; please write-in your county in next field.
*
Home Phone Number
*
Work Phone Number
*
Mobile Phone Number
*
Best number to call: (Choose One)
*
Home
Work
Mobile
NONREFUNDABLE DEPOSIT $ 75.00 (required – paid to Los Angeles Co. 4-H)
*
ADDITIONAL AMOUNT FAMILY, CLUB, OTHER WILL PAY $ __________ (do not include the deposit in this amount)
*
AMOUNT REQUESTED FROM RPA MEMORIAL CAMPERSHIP FUND $ __________ (Maximum of $150.00)
*
TOTAL SUMMER CAMP REGISTRATION FEE $_________ (If deposit is paid prior to 05/01/2020)
*
(Digital Signature) Signature of Parent/Guardian
*
Date of Application (Day/Month/Year)
*
Robert P. Amman Memorial Campership Fund
9401 Reseda Blvd., Ste. 100
Northridge, CA 91324-2973
Tel: (818) 280-0280
Email:
[email protected]
Web:
www.4hcampership.com
* Note: When you have completed the 4-H Summer Camp Campership Application please PRINT the page to save a copy before hitting sent.
* Note: You will directed back to the Campership Application page so that you can read all the disclaimers on the application.
Submit your online application
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