___X_Youth _____ Adult
___ Youth ___ Adult ___ CAL Staff
C.A.L. 2015
“Creating A Leader”
“Blast From the Past; Leadership through the decades”
January 23, 24, 25 2015
Registration Form
Due to your County Extension Office by November 18, 2014
Name (please print legibly) __________________________________________________________
Address______________________________________________________ Male ___ Female ___
City______________________________ Zip______________ County_____ ____________________
Phone Number ( ___)_____ _-___________ Age _____Grade_____ Previous No. yrs attending CAL _____
Parent E-mail (please print legibly) _________________________________________________________
Yes No Do you have any food allergies?
If yes, please explain on the back of this sheet. It is difficult to meet all of the needs of guests with specific food requirements (i.e., wheat allergies, vegan, etc.) We will do what we can in cooperation with Walker Creek Ranch.
Yes No ___ Will you bring medication? If yes, please explain in detail on the back of this sheet.
Yes ___ No ___ (Youth) I would like to be a County Contact, I would like to help lead my county’s orientation and
be the main youth contact from the CAL Staff to my county. Contact Jesse O. at jesseosman23@ for
more information.
Yes ___ No___ (Youth) I would like to be a Cabin Leader. I will attend a training meeting January 3rd 2015 in
Fairfield CA. I have attended C.A.L. once before and am in 8th grade or above Contact Lianna W. at
lianna.webber99@ or Jacob H. at jacob.hinkle727@ for more information.
Yes ___ No___ (Youth) I am willing to help present an education workshop. I will attend a training meeting
January 3rd 2015 in Fairfield, CA. Contact Kyle McMann at highhealth98@ for more information.
Yes No ___ I would like a CAL Conference T-shirt for an additional $10. Please circle your size:
Youth- Small Medium Large Adult- Small Medium Large X-Large
I plan to travel to the Conference with_____________________________________________________
_____ _______
Signature of: CAL Conference Delegate (4-H member)/ CAL Adult Chaperone (4-H volunteer) Date
_______
Signature of: County 4-H Advisor/ County 4-H Office Coordinator/or County 4-H Office Representative Date
The fee for the weekend is $160.00 ($170 if you would like a shirt)
Last day for refunds- December 21, 2014 Requests need to be sent straight to Lance Elder lqecon@
Make checks payable to your own County Council
Check List:
1. Registration Form for all attendees
2. Check for $160.00 (or $170 to include shirt)
3. Signed Medical Treatment Form by all attendees, adults & youth
4. Signed NSC 4-H Code of Conduct by all attendees, adults & youth
_____ 5. If a Chaperone, Chaperone Responsibility
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