Lake Cumberland 4-H Education Center, Jabez, KY

REGISTRATION FORM 4-H SHOOTING SPORTS WORKSHOP Lake Cumberland 4-H Education Center, Jabez, KY October 7 - 9, 2016

Name E-mail Address ______

 Agent  Volunteer  Teen Leader Age______** Sex______

Race*: Check all that apply:  American Indian  Asian  Black  Pacific Islander  White Are you:  Hispanic  Non-Hispanic *to comply with affirmative action Civil Rights Standard

Address ______City______

County ______State _____ Zip ______Phone ______

** In order to assure that counties have the certified leaders that their Shooting Sports programs need, teens will not be assigned to a class until all adults have been registered. PLEASE CHECK: Are you a First Time participant at a 4-H Shooting Sports Workshop in the state of Kentucky? ____Yes ____NO if not, please list previous Certification discipline(s).

Limits are placed on class sizes for the workshop. Since some classes fill faster than others, rank your preference for classes you would like to attend. (Please rank 1st, 2nd, 3rd etc.)

Coordinator ($60) Archery ($60)

22 Rifle/Air Rifle ($60) ______Range Safety Officer ($ 40) *Must be 21 years to sign up for this discipline* 22 Pistol/Air Pistol ($60) *Not available to first time participants*

Black Powder ($60) Hunter Challenge ($60)

Shotgun ($60) ______Hunter Education (Free)

After registering online, return Registration Fee with this Donna Fox Form to: 4-H Youth Development By September 23, 2016 (Fee payment must be 212 Scovell Hall, U.K. postmarked by this date) Lexington, KY 40546-0064 (Late registrations will not be accepted). (4-H Agent must sign off on the screening process below.)

4-H SHOOTING SPORTS FEES October 7 - 9, 2016 Fill in those costs appropriate to your arrival and departure times. First time participants should arrive between from 6-7:00 p.m. on Friday evening. Classes will begin at 7:30 pm on the dot. If you are a returning participant you may arrive Friday evening, but your classes will not begin until 8:30 am on Saturday. Registration fee is $60.00, EXCEPT for RSO, which is $40.00 and Hunter Ed (free) (Everyone will be required to room Double, Triple, or Quad...NO SINGLES!) See Cancellation Policy Below

NAME______COUNTY ______I wish to room with: ______Registration is not complete until fees have been received. MAKE CHECKS PAYABLE TO: Kentucky 4-H Foundation. Write Shooting Sports Registration on the memo line. Cancellation Policy: For cancellations not made prior to the week of the workshop or for any no shows, the registration fees will not be refunded. Classes are scheduled on a first registered, first paid basis. *Don’t forget about the Silent Auction. Proceeds benefit Shooting Sports Camp*