Mars Base Camp Boxes Registration

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Offered by Oneida County 4-H, Wisconsin: https://oneida.extension.wisc.edu.
If you would like to register more than 2 participants in your household, please fill complete an additional registration form (go back to the web page and click the registration link again).

Household Last Name *

Email Address: *

Best way to reach you when Mars Base Camp kits and/or information is ready to be distributed to or picked up by families: *

Phone (please write down phone number under "Other" below)

Other:

Required

House Number and Street Address: *

City *

State *

Zip Code *

Household Participant 1 First and Last Name *

Is Household Participant 1 a 4-H Member? *

Yes

No, but I would like him or her to become a 4-H member (4-H is free to join).

Household Participant 1 Grade Level: *

Household Participant 1 Race *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Prefer Not to Indicate

Other:

Required

Household Participant 1 Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Prefer Not to Indicate

Other:

Required

Household Participant 2 First and Last Name (*Skip if not applicable)

Is Household Participant 2 a 4-H Member?

Yes

No, but I would like him or her to become a 4-H member

Clear selection

Household participant 2 Grade Level:

Clear selection

Household Participant 2 Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Prefer Not to Indicate

Other:

Household Participant 2 Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Prefer Not to Indicate

Other:

Household Participant 3 First and Last Name (*Skip if not applicable)

Would you like to request an accommodation for a participant? *

Yes (please list accommodation requested in "other" below)

Other:

Required

The cost of this program is $5 per family in which at least one family participant is enrolled in Oneida County 4-H; OR $15 per family of household participants who are not enrolled in 4-H. Financial assistance is also available to all 4-H members. Select which option you will be registering for today: *

$5 for 4-H family registration

$15 for non-4-H family registration

Financial assistance requested. Please list the participant name(s) in the "Other" box below. The only individuals who will see these names are the UW-Extension 4-H Educator, and the Oneida County 4-H Leaders' Association adult president and adult treasurer. Names will not be shared with anyone else.

Other:

Required

I agree to pay the amount selected above by by sending a check written out to "Oneida County 4-H Leaders' Association" and mailing it to: Oneida County 4-H, UW-Extension Oneida County, 5350 College Dr., PO Box 518, Rhinelander, WI 54501, before picking up the box, OR call 715-365-2750 to arrange for a drop-off-payment at the 4-H Office. We are willing to work with families to try and make box distribution possible! *

I agree.

I need more information.

How did you hear about this activity?

School

Library

Newspaper

Radio

Facebook

Friend

County 4-H Program

Other:

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