1 of 1 5/7/2010 7:47 PM

Transcription

1 1 of 1 5/7/2010 7:47 PM _GoslinPat_AdultChaperone_noDog.pdf Page 1 of 9 4-H State Dog Conference Adult Instructors may only bring dogs needed for their training. Adult Chaperones may not bring a dog. Youth may bring up to 2 dogs. You will create a separate entry for each dog. American Breed Breed Herding Dogs: Select an item... Hounds: Select an item... Terriers: Select an item... Sporting Dogs: Select an item... Toys: Select an item... Non-Sporting Dogs: Select an item... Working Dogs: Select an item... Yes: Dog Dog Name: Dog Age: Select an item... Dog Height at Withers (if doing Agility): Select an item... Adult Chaperone, no dog allowed

2 1 of 1 5/7/2010 7:49 PM _GoslinPat_AdultChaperone_noDog.pdf Page 2 of 9 4-H State Dog Conference Senior Youth 15 & over may qualify as a Camp Counselor and/or an Event Volunteer. If paying by check, make payment to your County 4-H Program. For Event Questions, please contact Sally Manning, (813) , horsepny@tampabay.rr.com or Beverly Ruble, (863) , baruble@gmail.com Bill Heltemes, NE District RSA, State 4-H Office contact, (352) x242, whelteme@ufl.edu Adult Instructor or Chaperone? Adult Instructor Adult Chaperone 4-H State Dog Conference Registration Special Diet? Explain needs:: I hereby give my permission for the child named above to attend the H Dog Conference. Realizing that camp experiences are higher in risk than normal home activities, I hereeby release the Florida 4-H foundation, camp personnel, county leaders, and IFAS Extension Service from all liability for illness, accidents, and/or injuries resulting from camp activities and/or violation of rules where reasonable and prudent efforts have been made to ensure the safety and welfare of the participants. I understand that I must assume all responsibility for payment of physician and/or veterinary bills. I understand a local veterinarian will be on call during the conference. I authorize camp management to obtain veterinary care in case of emergency. I further agree that uncontrollable dogs may be sent home and that dogs without the required health records will not be allowed on the campgrounds. Considered a Parent/Guardian or Adult Participant Signature. I Agree. Yes No Parent/Guardian or Adult Participant Signature:: Pat Goslin Date: 5/7/10 4-H Agent Name: Matt Benge Type in name to indicate Agree T-Shirt: Adult XL Your Veterinarian Vet Name: Vet City: Vet Phone Number: Interests Clinics/ Activities - check all you would like to do Agility (dog must be at least 1 y r old): Rally: Showmanship: Costume Parade: Dog Tricks: Quiz Bowl:

3 1 of 1 5/7/2010 7:51 PM _GoslinPat_AdultChaperone_noDog.pdf Page 3 of 9 Cart 4-H State Dog Conference You are not finished yet! You will need to confirm in the upcoming steps. REGISTRATION INFORMATION Event Registrant Type Registration Fee 4-H State Dog Conference Adult Instructor or Chaperone $0.00 ENTRIES Number Registrant Name Amount Modify 1) 9 $0.00 ADDITIONAL FEES Item Description Quantity Amount Modify

4 1 of 1 5/7/2010 7:52 PM _GoslinPat_AdultChaperone_noDog.pdf Page 4 of 9 Payment 4-H State Dog Conference Payment Pay using a non-electronic method Personal Check Check Number County/Club 4H Check Check Number Purchase Order Purchase Order Number Billing Information is Incomplete Edit Billing Information

5 1 of 1 5/7/2010 7:52 PM _GoslinPat_AdultChaperone_noDog.pdf Page 5 of 9 Confirm 4-H State Dog Conference Your registration is not complete until you click 'Confirm Order'. Review Order ENTRY TYPE STATUS AMOUNT Adult Instructor or Chaperone Incomplete $0.00 ADDITIONAL ITEMS $0.00 REGISTRATION FEE $0.00 ORDER TOTAL $0.00 Payments will remain 'Pending' until Checks are received or Credit Cards and echecks are approved. BILL NAME METHOD NUMBER STATUS AMOUNT Personal Check Pending $0.00

6 1 of 2 5/7/2010 7:53 PM _GoslinPat_AdultChaperone_noDog.pdf Page 6 of 9 Finish 4-H State Dog Conference Printer Friendly Format Order Confirmation ENTRY TYPE STATUS AMOUNT Adult Instructor or Chaperone Pending - County $0.00 ADDITIONAL ITEMS $0.00 REGISTRATION FEE $0.00 ORDER TOTAL $0.00 Payments will remain 'Pending' until Checks are received or Credit Cards and echecks are approved. BILL NAME METHOD NUMBER STATUS AMOUNT Personal Check Pending $0.00 APPROVED PAYMENT TOTAL $0.00 Files to Download 1) 2010 Dog Conference Information Packet Information rules, Photo & Poster Contest info, Directions to Camp Cloverleaf 2) 4-H Photo Certification Statement Complete a form for each Photo, attach it to your photo, and bring if Entering the Photo Contest 3) Florida 4-H Dress Code Participants must adhere to this dress code. 4) Poster Certification Statement Complete and Bring this if Entering the Poster Contest Instructions Registration Info 4hfamily4@gmail.com Training Only County District 01 Confirmation Number 8 Registered On May 07, 2010 Event / Date / Time / Location Event Contact 4-H State Dog Conference For assistance, please contact the organizer: Date August 05, August 08, 2010 Beverly Ruble baruble@gmail.com Time 04:00 pm - 12:00 pm

7 2 of 2 5/7/2010 7:53 PM _GoslinPat_AdultChaperone_noDog.pdf Page 7 of 9

8 Registration Receipt 1 of 2 5/7/2010 7:54 PM May 07, _GoslinPat_AdultChaperone_noDog.pdf Page 8 of 9 Receipt Attached is the payment for: County: Training Only, District: 01 4-H State Dog Conference Please mail to:, Amount of payment: $ Please note receipt number: 9 on check Tear and enclose with payment. Payments received without payment stub may take longer to process. Invoice Information Confirmation Number: 8 Billing Name: Billing Address: Billing City: Billing State: Billing Zip Code: Event Information Event Title: 4-H State Dog Conference Event Date: Aug 05, 4:00 PM - Aug 08, 12:00 PM Contact Name: Beverly Ruble Contact baruble@gmail.com Contact Phone: Contact Web: Adult Instructors may only bring dogs needed for their training. Adult Chaperones may not bring a dog. Youth may bring up to 2 dogs. You will create a separate entry for each dog. Breed Herding Dogs: None Hounds: None Terriers: None Sporting Dogs: None Toys: None Non-Sporting Dogs: None

9 Registration Receipt 2 of 2 5/7/2010 7:54 PM _GoslinPat_AdultChaperone_noDog.pdf Page 9 of 9 Working Dogs: None American Breed Yes: No Dog Dog Name Dog Age: None Dog Height at Withers (if doing Agility): None