Washington County 4-H Camp in a Box Registration Form - Cooperative Extension in Washington County - University of Maine Cooperative Extension

Parent Name*

First Last

Address*

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

Home Phone

Cell Phone*

Email*

Youth in your Family*

To add more than one name, click on the small plus (+) sign at the end of the row

Name	Age	School

4-H Affiliation*

My child/children are enrolled in 4-H.
My child/children are NOT enrolled in 4-H.

4-H Boxes

Please select your first, second and third choices below. Boxes include:

All About Water | Backyard Birding | Family Fishing | Family Gardening | Tracking Wildlife

Box First Choice*

Box Second Choice*

Box Third Choice*

4-H Camp in a Box Sessions

Please select your first and second choices below. Boxes will be signed out for a week at a time. Boxes can be signed out on these dates:

Session 1: June 25-July 1 | Session 2: July 9-16 | Session 3: July 23-30 | Session 4: August 6-13

Session First Choice*

Session Second Choice*

4-H Camp in a Box Expectations

1. Adult supervision is required for all 4-H at-home activities

2. Be respectful and participate fully in the program

3. Treat the materials and kits with respect and be prepared to return them to the designated drop off location

4. Abide by all UMaine and State/Federal safety guidelines (this may include some restrictions due to COVID-19)

5. Submit photo/video documentation of your participation in this event

Expectations Consent*

Yes, I have read the 4-H Camp in a Box expectations and agree to this statement.

Photo release statement

I hereby grant and authorize the University of Maine System, acting through the University of Maine, (hereinafter UMS) its employees and agents to make use of, license or assign the use of, my image, appearance, likeness, voice and/or photograph, and other reproductions of any of these, in still photographs, videotapes, publications, audio, sound recordings, websites, electronic and other media and/or motion pictures, (hereinafter all of which are included in the term "Material") and to do so with or without mention of my name.

I understand and agree that I am to receive no compensation of any kind, monetary or otherwise, on account of or arising from the production, publication, recording, rebroadcasting, or other use of such Material.

UMS shall have complete ownership of the Material produced or published and shall have the exclusive right and license to make such use of that Material as it wishes, including, but not limited to the right of performance, display, reproduction and distribution in all media, and the right to create, perform, display and distribute derivative works of the Material.

I agree to indemnify and hold UMS, the University, its employees and agents, harmless from and against any and all claims, damages, lawsuits, judgments, and expenses, including reasonable attorneys' fees, that UMS may become liable to pay or defend arising out of or caused by any matter or material furnished or spoken by me in connection with my appearance.

I hereby release UMS, its employees and agents from all expenses, claims and liabilities incurred by me arising out of or in connection with my appearance and/or the use of the Material, except to the extent that those expenses, claims or liabilities are the direct result of the negligent acts or omissions of UMS, the University, its employees or agents.

Photo Release Statement*

Yes, I agree to this statement.
No, I don't agree to this statement.

Type your name here to sign electronically.*