Natural Resources Conservation Workshop Application

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1 Natural Resources Conservation Workshop Application Year Page 1 of 6 1. STUDENT INFORMATION (Please print or type, use black or blue ink) Student Name Age Gender Race Mailing Address City State Zip Grade High School Date of Birth Address County of Residence Sponsoring County (if different) I certify that I will be entering the 10 th, 11 th, or 12 th grade at the beginning of the school year. I have never attended a Natural Resources Conservation Workshop. I understand this is a workshop, and I will participate in all activities; show respect for property and facilities used; assume financial responsibility for any damage caused by me. I understand failure to follow the rules of conduct will result in my being sent home immediately. I UNDERSTAND THAT THE RULES OF CONDUCT PROHIBIT ANY USE OF TOBACCO PRODUCTS, ALCOHOL, OR DRUGS NOT PRESCRIBED BY DOCTOR AND THIS WILL BE STRICTLY ENFORCED. Student s Signature 2. TO BE FILLED OUT BY PARENT/LEGAL GUARDIAN (Please print or type, use black or blue ink) Parent or Guardian Name Mailing Address City State Zip Home Phone (include area code) Work Phone Cell Phone Address Media Release: I understand photographers and/or television crews will sometimes be present during classes, rehearsals, or performances of this workshop. I give permission for any resulting photographs or video, which may include my child, to be used by NRCW for any promotional purposes on the website, television, or in newspapers, magazines or any other media deemed appropriate. Yes No Parent/Guardian Relationship Date Completed applications must be received by May 24th. Pages 1 and 2 must be completely filled out with payment for the application to be processed. Applications are accepted on a first-come, first-served basis. Full refunds will be made if application is cancelled on or before May 24th. No refunds after May 24th. For additional information, contact Workshop headquarters at (229) or nrcw@abac.edu or

2 Page 2 of 6 Natural Resources Conservation Workshop To complete this form, Soil and Water Conservation District and Natural Resources Conservation Service information may be found on the following page or at SPONSORSHIP (To be completed by Agency and Supervisor) COUNTY OF SPONSORSHIP SOIL AND WATER CONSERVATION DISTRICT SPONSOR Sponsor Mailing Address City State Zip The following named Student: is recommended to attend the Natural Resources Conservation Workshop. BOTH District and NRCS SIGNATURES Signature of Soil & Water Conservation District Supervisor Date Are REQUIRED Signature of NRCS Representative Date Mail application with a check for $ to: NRCW ABAC Moore Highway Tifton, GA

3 Page 3 of 6 Georgia NRCS Offices by County Quick Directory January County Office Name Name Phone County Office Name Name Phone County Office Name Name Phone Appling Baxley Linda Campbell (912) Fayette McDonough Shaun Ford (770) Oglethorpe Washington Rory Richardson (706) Appling Seven Rivers RC&D (912) Floyd Rome Sheri Teems (706) Paulding Dallas Valerie Pickard (770) Atkinson Pearson Daniel Lavender (912) Forsyth Gainesville Buddy Belflower (770) Peach Byron Ray Jones (478) Bacon Alma Stacey Floyd (912) Franklin Broad River (706) ext. 3 Pickens Calhoun Doug Cabe (706) Baker Newton Eugene Barber (229) Fulton Marietta Valerie Pickard (770) Pierce Blackshear Dane Smith (912) Baldwin Eatonton Corey New (706) Gilmer Limestone Valley Douglas Towery (706) Pike Zebulon William Pitts (770) Banks Commerce Carol Boss (706) Glascock Louisville Craig Bevan (478) Polk Rome Sheri Teems (706) Barrow Oconee River Susan Peppers (770) Glynn Brunswick Rita Barrow (912) Polk Rolling Hills RC&D (770) Bartow Cartersville Carol Griner (770) Gordon Calhoun Doug Cabe (706) Pulaski Hawkinsville Jackie Busby (478) Ben Hill Fitzgerald CharleneLankford (229) Grady Bainbridge Marcus Collins (229) Putnam Eatonton Corey New (706) Berrien Nashville Stan Moore (229) Greene Greensboro Scotty Palmer (706) Quitman Cuthbert Karen Reese (229) Bibb Fort Valley Ray Jones (478) Gwinnett Lawrenceville Jerome Brown (770) Rabun Blairsville Douglas Towery (706) Bleckley Cochran Danny Bennett (478) Habersham Clarkesville Harold Thompson (706) Randolph Cuthbert Karen Reese (229) Brantley Brunswick Rita Barrow (912) Hall Gainesville Buddy Belflower (770) Richmond Augusta Cread Brown (706) Brooks Quitman Hal Dorsey (229) Hall Chest. Chat. RC&D (706) Richmond CSRCD (706) Bryan Richmond Hill James Austin (912) Hancock Greensboro Scotty Palmer (706) Rockdale Lawrenceville Jerome Brown (770) Bulloch Statesboro Glynn Thrift (912) Haralson Carrollton Cindy Haygood (770) Schley Americus Mark Rhodes (229) Burke Waynesboro Stuart Proctor (706) Harris Hamilton Jack McClung (706) Screven Sylvania Austin Blackburn (912) Butts Jackson Shaun Ford (770) Hart Hartwell Forrest Ferguson (706) Seminole Donalsonville Anita Tabb (229) Calhoun Morgan Lynne Roney (229) Heard Newnan Kevin Keel (770) Spalding McDonough Shaun Ford (770) Camden Brunswick Rita Barrow (912) Henry McDonough Shaun Ford (770) Stephens Toccoa Russell Biggers (706) Candler Metter Stephanie Williams (912) Houston Perry Calvin Essex (478) Stewart Americus Marcus Rhodes (229) Carroll Carrollton Sam Sharpe (770) Irwin Fitzgerald-Ocilla Roy Joiner (229) Sumter Americus Marcus Rhodes (229) Catoosa Lafayette Cindy Askew (706) Jackson Commerce Carol Boss (706) Talbot Buena Vista J. Fokes, Jr. (229) Charlton Waycross (912) ext. 3 Jasper Monticello Dennis Brooks (706) Taliaferro Greensboro Scotty Palmer (706) Chatham Richmond Hills James Austin (912) Jeff Davis Baxley Linda Campbell (912) Tattnall Statesboro Glyn Thrift (912) Chatt. Buena Vista J. Lewis Fokes, Jr. (706) Jefferson Louisville Craig Bevan (478) Taylor Byron Ray Jones (478) Chattooga Rome Sheri Teems (706) Jenkins Millen Theron Cates (478) Telfair McRae Keith Granger (912) Cherokee Canton Joe Bishop (678) Johnson Wrightsville Stephen Rabitsch (478) Terrell Dawson Rich Hosmer (229) Clarke Monroe Jose Pagan (770) Jones Gray Dennis Brooks (706) Thomas Thomasville Phil Smith (229) Clay Cuthbert Karen Reese (229) Lamar Barnesville Carmen Westerfield (770) Tift Tifton (229) ext. 3 Clayton McDonough Shaun Ford (770) Lanier Lakeland Robert Joyce (229) Toombs Lyons Kerry Collins (478) Clinch Nashville Stan Moore (229) Laurens Dublin Britt Parker (478) Towns Blairsville Douglas Towery (706) Cobb Marietta Valerie Pickard (770) Lee Leesburg Melissa Golden (229) Treutlen Swainsboro Sidney Lanier (478) Coffee Douglas Zack Riley (912) Liberty Richmond Hill James Austin (912) Treutlen Pine Country RC&D (912) Colquitt Moultrie Paul Long (229) Liberty Coastal GA RC&D (912) Troup Newnan Kevin Keel (770) Columbia Augusta Cread Brown (706) Lincoln Washington Rory Richardson (706) Troup Two Rivers RC&D (706) Cook Nashville Stan Moore (229) Long Richmond Hill James Austin (912) Turner Ashburn Del Braziel (229) Coweta Newnan Kevin Keel (770) Lowndes Valdosta Phil Hall (229) Twiggs Eastman Charles McCranie (478) Crawford Fort Valley Ray Jones (478) Lumpkin Gainesville Buddy Belflower (706) Union Blairsville Douglas Towery (706) Crisp Cordele Graylen Hall (229) Macon Oglethorpe Tracy Crawford (478) Upson Barnesville Carmen Westerfield (770) Dade Trenton Joe Lee (706) Madison Commerce Carol Boss (706) Walker LaFayette Cindy Askew (706) Dawson Gainesville Buddy Belflower (770) Marion Buena Vista J. Lewis Fokes, Jr. (229) Walton Monroe Jose Pagan (770) Decatur Bainbridge Marcus Collins (229) McDuffie Thomson Ervin Hart (706) Ware Waycross (912) ext.3 DeKalb Lawrenceville Jerome Brown (770) McIntosh Richmond Hill James Austin (912) Warren Louisville Craig Bevan (478) Dodge Eastman Charles McCranie (478) Meriwether Newnan Kevin Keel (706) Washington Sandersville Galen Wilson (478) Dooly Cordele Graylen Hall (229) Miller Colquitt Deborah Henry (229) Wayne Jesup Paul Harris (912) Dougherty Albany Vontice Jackson (229) Mitchell Camilla Dan Baker (229) Webster Preston Mike Goare (229) Douglas Douglasville Sam Sharpe (770) Monroe Forsyth Carmen Westerfield (770) Wheeler Alamo Leslie Woodard (912) Early Blakely Steven Cleland (229) Montgomery Mt. Vernon Scotty Thomas (912) White Toccoa Sherrill Dockery (706) Early Golden Triangle RC&D (229) Morgan Madison Dennis Brooks (706) Whitfield Lafayette Nick Mooneyham (706) Echols Nashville Stan Moore (229) Murray Lafayette Cindy Askew (706) Wilcox Rochelle Sylvester Bembry (229) Effingham Springfield Charles Branch (912) Muscogee Columbus Eddie Edwards (706) Wilkes Washington Rory Richardson (706) Elbert Elberton Katrina White (706) Newton Covington Amy Robinson (770) Wilkinson Dublin Britt Parker (478) Emanuel Swainsboro Sidney Lanier (478) Newton Covington SS James Toman (478) Worth Sylvester Darrell Clayton (229) Evans Statesboro Glyn Thrift (912) Oconee Watkinsville Gerald Grace (706) Fannin Blairsville Douglas Towery (706) Oconee Oconee RC&D (706)

4 Page 4 of 6 RETURN THIS PAGE WITH YOUR APPLICATION. ANSWER ALL INFORMATION COMPLETELY BEFORE SUBMITTING APPLICATION. IF NO RESPONSE, INDICATE WITH [N/A]. Phone numbers are required. Fee and Required Medical Information Form must accompany application. Required Medical Information Please print clearly. This information will be kept on file in the Natural Resources Conservation Workshop Headquarters. Name Date of Birth Basic information is needed in an emergency so proper medical attention may be given during the workshop. Please provide the information below and submit any other information you feel is applicable. Include a copy of your health insurance card, if available. (1) Drug Allergies (2) Other Allergies (3) Is there a history of heart disease, diabetes, epilepsy, rheumatic fever, asthma, or other serious conditions? Please list condition(s) and note any special conditions. (4) Have you been diagnosed with any other health/behavior disorders (ADD, ADHD, etc.)? Please list diagnosis and note any special conditions. (5) Are there any physical restrictions? Please describe (6) Date of last tetanus immunization (7) Are you taking any medications (non-prescription) at the present time? If yes, please list type of medications. (8) Name of Family Physician Phone (9) Names of persons (other than a parent or guardian) that may be contacted in case of an emergency (print or type): 1. Name Phone 2. Name Phone PARENTAL/LEGAL GUARDIAN CONSENT AND RELEASE FROM LIABILITY I/We, the undersigned parent(s)/legal guardian(s) of the above identified minor, do hereby consent to his/her participation in the workshop named above and do forever release, acquit, discharge, and agree not to sue Natural Resources Conservation Workshop staff and sponsors, its members individually, and its officers, agents and employees from all claims, demands, rights, and causes of action of whatever kind or nature, arising from and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property and the consequences thereof, resulting from participation in and in any connection with such workshop. In the event that my child becomes ill or sustains injury while in the care of the Natural Resources Conservation Workshop staff, I give permission to administer first aid to him/her. I also give permission to admit my child to any hospital for such treatment as deemed necessary. Signed Date Relationship THIS BLANK MUST BE COMPLETED: My transportation will be by Example: Bus, van, parents, etc. (personal cars cannot be driven to the workshop.)

5 Page 5 of 6 Keep this page as your Bus Boarding Pass! This page is not needed if you are not riding a district bus. Contact your Local Soil and Water Conservation District directly for information on buses, boarding locations and travel times. Natural Resources Conservation Workshop Bus Transportation--Medical Information Sheet Current medical information is needed in case of an emergency during bus transportation. Please complete the blanks below and submit other information you feel is applicable. Participant s Name Date of Birth Grade Gender Race Home Address: Street or P. O. Box City State Zip Phone: Evening Daytime Other Phone Drug Allergies Other Allergies Date of Last Tetanus Immunization Date of physical examination Any of the following conditions exist: Heart Conditions, Diabetes, Epilepsy, Rheumatic Fever, ADD/ADHD, Other Are there any physical restrictions? If yes, describe: Are you taking any medications at the present time? Yes No List: Name of Family Physician: Phone: In the event that my child becomes ill or sustains injury while in route to or from the Natural Resources Conservation Workshop, I give permission to administer first aid to him/her. I also give permission to admit my child to any hospital for such treatment as deemed necessary. Signature-Parent/Legal Guardian Date NAME OF TWO PERSONS OTHER THAN PARENTS/LEGAL GUARDIAN THAT MAY BE CONTACTED IN CASE OF EMERGENCY. Name Phone:( Name Phone:( ) ) Give this page to your bus driver before boarding if riding a district-sponsored bus

6 Page 6 of 6 STUDENT APPLICATION CHECKLIST Natural Resources Conservation Workshop Fill out the application completely and sign. Your signature on page 1 is mandatory. Have parent/guardian sign pages 1, 4 and 5 of the application. Did your NRCS Representative and District Supervisor sign page 2 of the application? Is the Medical information page answered completely? If an answer doesn t apply in the medical information, respond by filling in the blank with N/A. Include a copy of your health insurance card, if available. Did you include all phone numbers on your application? Did you include two emergency contacts on your application with phone numbers? If you need to ride a Soil and Water Conservation District (SWCD) sponsored bus, did you remember to contact your local soil and water district in a timely fashion in order to schedule a pick-up time? If you are riding a SWCD sponsored bus to camp, did you remember to complete page 5 of the application and keep it with you as a bus-boarding pass? If your parent/guardian is transporting you to camp, it is not necessary to complete page 5 of the application. You will not be able to drive your personal vehicle to the workshop. Make your check for $150 payable to: Natural Resources Conservation Workshop Mail the check and pages 1, 2, and 4 to: NRCW ABAC Moore Highway Tifton, GA

COUNTY Provider Rep Phone

COUNTY Provider Rep Phone APPLING Brittany Krivit (912)346-8588 ATKINSON Ericca Williams (229) 376-0163 BACON Brittany Krivit (912)346-8588 BAKER Darla Evans (229) 289-6738 BALDWIN Jeannie Teter (478)