This is a Special Registration form for the 2011 Camp Corral at Millstone 4-H Camp in Ellerbe, North Carolina. It is exclusively
for 8 to 15 year old children of military personnel. Priority will be given to children of wounded or disabled military families. Once your registration request has been processed you will be contacted directly by the Millstone 4-H Camp.

CAMP WEEK YOU ARE APPLYING FOR:  July 3-8    July 17-22 (FULL)    July 31-Aug. 5 (FULL)

CAMPER'S INFORMATION

NAME:  First*:  

Middle:  

Last*:  

Address*:  

City*:  

State*:  

Zipcode*:  

County*:  

Phone*:  

  (xxx-xxx-xxxx)

Email:  

  Female           Male

Date of birth *:  

  (mm/dd/yyyy)

Grade*:  

T-Shirt Size:  

Youth:
  S      M      L      XL

Adult:
  S      M      L      XL      XXL      XXXL      XXXXL

ETHNIC GROUP: **

Select all that apply:  

  White or Caucasian
  Black or African-American
  Hispanic or Latino
  American Indian or Alaska Native

  Asian
  Native Hawaiian or other Pacific Islander
  Other  

Place of residence *:  

  Farm
  Town under 10,000 people or rural non-farm
  City 10,000-50,000 people
City over 50,000 people
  Suburbs of city over 50,000 people
  Military installation - Specify:  

PARENT OR GUARDIAN INFORMATION:

NAME:  First*:  

Middle:  

Last*:  

Is Parent/Guardian address the same as camper's address?
Yes
No (Please fill address below)

Address*:  

City*:  

State*:  

Zipcode*:  

Home Phone*:  

  (xxx-xxx-xxxx)

Cell Phone*:  

  (xxx-xxx-xxxx)

Work Phone:  

  (xxx-xxx-xxxx)

Email*:  

This email address will only be used to convey acceptance and other information about camp to the parent/guardian.

*ADDITIONAL EMERGENCY CONTACT INFORMATION (Contacts to be from Two (2) separate households and not Parent/Guardian listed above:

NAME:  First:  

Last:  

Home Phone:  

  (xxx-xxx-xxxx)

Cell Phone:  

  (xxx-xxx-xxxx)

Work Phone:  

  (xxx-xxx-xxxx)

Relationship to Child:  

NAME:  First:  

Last:  

Home Phone:  

  (xxx-xxx-xxxx)

Cell Phone:  

  (xxx-xxx-xxxx)

Work Phone:  

  (xxx-xxx-xxxx)

Relationship to Child:  

DEMOGRAPHIC/GENERAL INFORMATION:

Military Component:*  
Check all that apply   

  Air Force
  Army
  Navy
  Marine Forces
  Coast Guard
  Army National Guard

  Air Force Reserve
  Army Reserve
  Navy Reserve
  Marine Forces Reserve
  Coast Guard Reserve
  Air National Guard

  Veteran     List branch or component

Service Member's relationship to child*:  

  Mother      Father      Stepmother      Stepfather      Sibling      Aunt      Uncle      Grandparent   

Camper is the child of a service member who is:  

  Disabled as a result of military service
  Fallen, KIA
  Injured/wounded in the line of duty
  Currently deployed  (return date:  )
  Home, but was deployed sometime within the last 12 months  (return date:  )
  Scheduled to deploy in the next 6 months  (deployment date:  )
  Scheduled to deploy in the next 12 months  (deployment date:  )
  Not scheduled to deploy at this time

Does the child have more than one parent/guardian currently deployed?:  

  Yes      No   

Does the child normally reside with the service member a total of six months or more during the year?:  

  Yes      No   

The following relatives are currently deployed or scheduled to deploy: (check all that apply):  

  Mother      Father      Stepmother      Stepfather      Sibling      Aunt      Uncle      Grandparent      None   
  Other    If other, relationship to child:  

How many times has your family moved to a new military installation (PCS)?  

Has your child attended an Operation Purple or other sponsored camp for military youth?:  

  Yes      No   

If yes, which summer(s) did your child attend camp? (check all that apply):  
  2007     2008     2009     2010  

Have you noticed any changes (positive or negative) in your child since the deployment or news of a pending deployment? (check all that apply):  

  Difficulty with school work  
  Immersion in school work or activities  
  Quiet or socially withdrawn  
  Hyperactivity  
  Depression  
  Anger  
  Sad  
  Denial  

  Acting out more  
  Eating habits change  
  Fearful for service member's safety  
  Sleeplessness/change in sleep habits  
  Confusion as to where and why parent has gone  
  Child assumes more responsibilities  
  No change  
  Other  
Explain other:  

SPECIAL NEEDS

Dietary Needs:
  Vegetarian (eat eggs, dairy)  
   Vegan (no eggs, dairy, animal products of any kind)  
  Other diet restrictions  
Explain other:  

Please describe any other special needs or accommodations that may be required to enable your child to participate in this program:

INFORMATION DISCLOUSURE AGREEMENT:

I.  I, the applicant voluntarily provide required information with this application to register my child for Camp Corral summer camp. To this end, I fully understand that:

• Participation in Camp Corral summer program is voluntary
• The requested information is needed for participation
• The principle purpose of the requested information is to:
• Verify the identity of the applicant
• Verify the identity of the child wishing to participate in the Camp Corral camp program
• Determine eligibility for the camp program
• Gather information about children and deployment to be used to enhance the camp program and possibly create additional programs to meet the needs of military children

II.  I understand I must provide at least two weeks notice in the event I need to cancel my child's camp reservation.

III.  I understand further that:

• Completing this application does not guarantee acceptance to Camp Corral summer camp.
• If selected, I must complete and return by the deadline, ALL required forms to the camp my child is attending in order to retain a spot at camp.

IV.  I submit that I have read and understand the disclosure agreement above, and to the best of my knowledge my application information is correct and complete.

V.  As the parent/guardian of a camper who will attend Camp Corral, I do fully understand the rustic nature of the camp facilities, the liability policy under which the camp will operate, and do hereby give my consent for my child to participate in this camp under these conditions. I also understand that my child's personal property is not insured against loss or damage. Any loss or damage to personal property or injury to camper will be at my (the parent's/guardian's) risk and expense.

Forms To Be Completed Upon Selection:

1. NC Department of 4-H Youth Development Health History and Custody Release Form
2. 4-H Medical Information and Informed Consent for Treatment for NC 4-H Sponsored Events Form
3. North Carolina 4-H Centers 4-H Camper Code of Conduct Form
4. Parent's Agreement and Consent Form
5. North Carolina and County 4-H Photographic, Video and Audio Optional Publicity Release Form
6. NC 4-H Enrollment Form
7. IRB Release Form

Parent or Guardian Signature*
   Typing your name is considered the same as signing.

Participant's Signature*
   Typing your name is considered the same as signing.

**This information is required for all federally assisted programs and is solely used for the purpose of determining compliance with Federal civil rights laws; your responses will not affect consideration of your application. By providing this information, you will assist us in assuring that this program is administered in a nondiscriminatory manner.