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Northern Wisconsin 4-H Shooting Sports Adult Certification Workshop Registration Form

IF YOU HAVE DIFFICULTY WITH THIS REGISTRATION FORM OR DO NOT RECEIVE A CONFIRMATION EMAIL UPON COMPLETING REGISTRATION,
please call Doug Thompson at 920-391-4657 or the UW Extension office at 920-391-4650.
.
May 17 - 18, 2019


Northern Wisconsin 4-H Shooting Sports Adult Certification Workshop
(MUST BE 21 YEARS OF AGE OR OLDER)
Price County UW-Extension Office
104 S. Eyder Avenue
Phillips, WI 54555


Friday, May 17, 2019 – 6-10 pm – Saturday, May 18, 2019 – 8 am-5 pm
Please note: If you completed a Friday evening Guidelines Session in 2016, 2017 or 2018 you need only register for a Saturday discipline of choice and pay a reduced $55 workshop fee. All certifications require attendance at the complete 8- or 12-hour workshop. Registration Deadline: Friday, May 3, 2019 (Contact Doug Thompson at 920-391-4657 after this date for availability.)

Certifications: Archery, rifle/air rifle, shotgun

Registration Deadline: May 3, 2019

Fee for both Friday and Saturday Sessions: $70* (Includes instructor manual, equipment, ammunition, Friday pm snack, Saturday lunch, and Saturday am and pm snacks.) Please check in before 6 pm on Friday and before 8 am on Saturday.

Fee for Saturday Discipline Certification only: $55* (Includes instructor manual, equipment, ammunition, Saturday lunch, and Saturday am and pm snacks.) Please check in by 8 am on Saturday.

*Reduced Fee for one spouse if both spouses attend same workshop/discipline: $25 (When both spouses attend the same certification workshop taking the same discipline the $25 rate for one spouse applies. $70+$25=$95 or $55+$25=$80.)

YOU WILL MAKE ONLINE PAYMENT ONCE YOUR REGISTRATION IS SUBMITTED, you will be re-directed to a secure website for payment. Be sure to click on the down arrow in the box next to Program Area and select 4-H Shooting Sports Workshop.
If you have any questions or difficulties with this form, please call
Extension Brown County office at 920-391-4650.


If you have any questions regarding the Shooting Sports Program, please email
doug.thompson@ces.uwex.edu or call 920-391-4657.


Weather Conditions: Outside ranges may be used; dress appropriately for outdoor conditions.


Registration Form
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Email Address:
Comments:
Home Telephone Number:
Cell Phone Number:
Name of County where you will be a shooting sports instructor::
Check all that apply::
Adult 4-H Leader currently enrolled in a county 4-H program through 4-H Online
I am NOT currently enrolled in a county 4-H program through 4-H Online
I am enrolled in a county 4-H program, but have NOT completed required 4-H Leader Orientation
This is the first time I have ever attended a 4-H Shooting Sports Certification
I am currently certified in at least one 4-H Shooting Sports Certification
I want to be certified to teach for another organization, but not 4-H. (Please name the organization in the box below)
I want to be certified to teach for another organization, plus teach in 4-H (Please name the organization in the box below)
Discipline Certification Requested - YOU CAN ONLY BE CERTIFIED IN ONE DISCIPLINE AT A WORKSHOP:
Archery
Air Rifle/.22 Rifle
Shotgun
Saturday lunch sub choice:
ham
turkey
veggie
Please provide diet restrictions::
Please describe any limitations or restrictions regarding your participation in event activities or any accommodations
(such as an interpreter for hearing-impaired or wheelchair accessibility) you may need:
Need certification for another organization - list organization:
Adult 4-H SS Leader - list disciplines held:
I will be attending:
May 17 - 18
May 18
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