Aurora County Day Camp/4-H Project Day
Please complete the form below. Note that when you submit the registration form you are agreeing to the Camper Agreement as presented below.  We are using Sanborn County 4-H's website for this form but all correspondence and registrations will be sent to Cheryl Dethlefsen and Tina Kieffer. If you have questions, please call Tina at 605.942.7754 or email Aurora.County@sdstate.edu

* indicates required fields 
  *Parent/Guardian Name:
  Address:
  Phone:
  Email:
  Emergency Contact Name if different than above:
  Emergency Contact Phone if different than above:
  Camper #1 Name:
  Date of Birth:
  Gender:  Male
 Female
  Grade just completed:
  Age:
  Camper Health Information:  Nothing of concern to report for day camp
 Health conditions to be aware of (allergies, asthma, diabetes, etc) please list
  Camper Health conditions to be aware of:
  Camper #2 Name:
  Date of Birth:
  Gender:  Male
 Female
  Grade just completed:
  Age:
  Camper Health Information:  Nothing of concern to report for day camp
 Health conditions to be aware of (allergies, asthma, diabetes, etc) please list
  Camper Health conditions to be aware of:
  Camper #3 Name:
  Date of Birth:
  Gender:  Male
 Female
  Grade just completed:
  Age:
  Camper Health Information:  Nothing of concern to report for day camp
 Health conditions to be aware of (allergies, asthma, diabetes, etc) please list
  Camper Health conditions to be aware of:

By submitting registration, I agree to the Camping Agreement Between campers, parents, staff and volunteers: Camper must be ready to participate in group activities and learn new skills - get involved. Camper must respect staff and volunteers and other campers. I hereby authorize Aurora County 4-H to photograph my children, and authorize Aurora County 4-H, its legal representatives, or successors and assigns the absolute right and unrestricted permission to copyright, publish and/or use such photographs or recordings in whole or part, or composite form made for art, advertising, trade or any other lawful purpose. I hereby waive any right that I may have to inspect and approve the finished product or the advertising copy that may be used in connection therewith, or the use to which it is applied. I understand no payment or compensation will be provided to use my photograph or recordings. I hereby release, discharge and agree to hold harmless Aurora County 4-H from any liability by virtue of any use whatsoever, whether intentional or otherwise, that may occur or be produced in the taking of said picture, or in any processing needed to complete the finished product. I give my permission to have my child treated by a medical doctor in the case of serious injury/illness. If the person requires hospitalization, I understand my presence at the hospital is required as soon as possible. I understand that he/she will be properly supervised by arrangements and the total expense will be the responsibility of the youth’s parents/legal guardian. Aurora County 4-H is not responsible for any accident/injury or lost/stolen items during the duration of camp. Aurora County 4-H cannot be held responsible for information that is not disclosed honestly on this form. Some of the activities may include some risk including running, climbing and other activities. I release Aurora County 4-H and its entities and volunteers from any liabilities in case of injury on June 29, 2022.

All correspondence and registrations for this Aurora County 4-H Day Camp will be sent to Cheryl Dethlefsen and Tina Kieffer.  If you have questions, please call Tina at 605.942.7754 or email Aurora.County@sdstate.edu

 

Audra Scheel, 4-H/Youth Advisor
Sherryl Rankin, Secretary 

 Phone: (605) 796-4380
Email: Sanborn.County@sdstate.edu

PO Box 397
Woonsocket SD  57385-0397


 
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