relations, trade or any other lawful use, Registration for Pierce County 4-H information about my participation Boys or girls entering 6th, 7th, or 8th child’s Gateway Academy in this program and reproductions grade in the fall of 2016. (photographic or otherwise) of my child’s voice, likeness and any related creative Student Name Interested in science, technology, works produced. engineering or math careers. First: I have read all statements above and fully Comfortable working in a fast-paced understand the contents. This release Last: environment. and contract shall be binding upon me Grade: (2016-17 school year) and my legal representatives. Curious about how things work. Address Parent or Guardian Printed Name Willing to participate in the activities Street: and the field trip. Parent or Guardian Signature and Date City/Zip: Eager to have fun, learn something Send completed registration form & check to: new, and make new friends. Pierce County UW-Extension Parent or Guardian Name: 412 West Kinne Street Ellsworth, WI 54011-0069 The 4-H Gateway Academy is a joint Make check payable to: venture of Home Phone: Pierce County 4-H Adult Advisors University of Wisconsin-Extension, the Society of Manufacturing Engineers T-Shirt Size Circle Below – – Cell Phone: (SME) Education Foundation, and River Youth Large Adult Small Adult Med. Falls School District E-mail: Adult Large Adult XL 4-H GATEWAY REGISTRATION Media Release (please check one) Day Campers will be selected on a first-serve basis (limited to first 20) by ___ I grant permission completing the registration in this brochure and payment of a non-refundable $100.00 ___ I do not grant permission fee, which includes a t-shirt, field trip, lunches, and all classroom materials for the I grant the University of Wisconsin Board week. A portion of fee may be refunded if of Regents, University of Wisconsin additional Academy funding is obtained. Extension and River Falls School District and agents unlimited permission to For additional information please contact: copyright and use, publish, and republish Frank Ginther, 4-H Youth Development for purposes of advertising, public Agent, or 715-273-6781.
Boys or girls entering 6th, 7th, or 8th grade in the fall of 2016. Interested in science, technology, engineering or math careers. Comfortable working in a fast-paced environment. Curious about how things work. Willing to participate in the activities and the field trip. Eager to have fun, learn something new, and make new friends. The 4-H Gateway Academy is a joint venture of University of Wisconsin-Extension, the Society of Manufacturing Engineers (SME) Education Foundation, and River Falls School District 4-H GATEWAY REGISTRATION Day Campers will be selected on a first-serve basis (limited to first 20) by completing the registration in this brochure and payment of a non-refundable $100.00 fee, which includes a t-shirt, field trip, lunches, and all classroom materials for the week. A portion of fee may be refunded if additional Academy funding is obtained. For additional information please contact: Frank Ginther, 4-H Youth Development Agent, or 715-273-6781. Registration for Pierce County 4-H Gateway Academy Student Name First: Last: Grade: (2016-17 school year) Address Street: City/Zip: Parent or Guardian Name: Home Phone: Cell Phone: E-mail: Media Release (please check one) ___ I grant permission ___ I do not grant permission I grant the University of Wisconsin Board of Regents, University of Wisconsin Extension and River Falls School District and agents unlimited permission to copyright and use, publish, and republish for purposes of advertising, public relations, trade or any other lawful use, information about my child’s participation in this program and reproductions (photographic or otherwise) of my child’s voice, likeness and any related creative works produced. I have read all statements above and fully understand the contents. This release and contract shall be binding upon me and my legal representatives. Parent or Guardian Printed Name Parent or Guardian Signature and Date Send completed registration form & check to: Pierce County UW-Extension 412 West Kinne Street Ellsworth, WI 54011-0069 Make check payable to: Pierce County 4-H Adult Advisors T-Shirt Size – Circle Below – Youth Large Adult Small Adult Med. Adult Large Adult XL