Youth Cooking Camp Registration

Important! Please do not sign up your child unless they will be able to attend all days.*

My youth will be at ALL days of the camp.

Youth Name*

First Last

Age (as of date of program)*

Please enter a number from 9 to 14.

Date of Birth (MM/DD/YYYY)*

Gender

Male

Female

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

Parent/Guardian Name*

Contact Number (if different than above)

Email Address (if different than above)

Would you like to volunteer to help with the cooking camp?

Yes

Emergency Contact Name: Please give a different person than the original parent or guardian in the event we can't get ahold of the one already provided.*

Emergency Contact Number (Please give a number that is different than the one already provided in the event that we can't get ahold of the parent or guardian)*

Please list any medical information for each youth (Allergies, Asthma, Medicine, Seizures, etc)

Health Care Provider*

Insurance Policy Number*

Name of Insured*

Hospital Preference*

Additional Information we should know:

I, hereby give my consent as the parent/guardian of my child, for his/her involvement in the Orange County Summer Youth Cooking Camp at Texas A&M AgriLife Extension Orange County, 11475-A FM 1442, Orange, TX 77630, (409) 882-7010. Orange County 4-H staff and adult volunteers will provide supervision. I hereby release, waive, Indemnify and hold harmless Orange County 4-H and its agents/representatives in the events of injury to my child, and hereby waive, release and forever discharge any and all rights and claims against them. I further understand that Orange County 4-H or its representatives will not provide any form of medical insurance and that Orange County 4-H or its agents/representatives will not be responsible for any expenses incurred as a result of injury, illness, loss or accident, to the person(s) or property of my child/children, while attending this function. In case of an emergency, I give the agents/representatives of Orange County 4-H permission to secure emergency care for my child/children in my absence.*

Parent First Name Parent Last Name

I (give/do not give) permission to have my child’s picture published on websites, newspapers, Facebook, etc.*

Give Permission

Do Not Give Permission

I understand that if the behavior of my youth causes any disruption in the planned activity, I will be called at once to come and pick up my youth immediately at the site of the activity.*

First Last

Youth Cooking Camp

Price:

Total Cost

How will you be paying for the camp?*

Cash

Check

PayPal

Credit Card

If you are paying with Cash, mail or drop off at the following address: Texas A&M AgriLife Extension-Orange County, 11475-A FM 1442, Orange, TX 77630. Please send a copy of your registration or a note with who and which camp you are paying for. We do not recommend sending cash through the mail.

If you are paying by Check, make it payable to H.O.P.E. and mail or drop off at the following address: Texas A&M AgriLife Extension-Orange County, 11475-A FM 1442, Orange, TX 77630. Please send a copy of your registration or note on the check which camp and who you are paying for.

If you are using PayPal to pay, Send money to the PayPal Personal (Not Business) account orange-tx@ag.tamu.edu. Please note which camp and who you are paying for in the message section.

We accept credit and debit cards in the office but we will charge a 3.5% fee to use it (we will not run a card over the phone). You will need to come to Texas A&M AgriLife Extension Office in Orange County at 11475-A FM 1442, Orange, TX 77630.

Extension Educationin Orange County

Texas A&M AgriLife Extension Service

Youth Cooking Camp Registration

Youth Cooking Camp Registration

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