OLD Online Campership Application

2022ROBERT P. AMMAN MEMORIAL CAMPERSHIP ONLINE APPLICATION

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) *

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