Indiana 4-H Shooting Sports Instructor Workshop Registration Form
September 8th - 10th, 2017 - Ross Camp, Tippecanoe County

Each year IDNR's Hunter Education Program, in relation with Purdue University, provides two training workshops for the 4-H Shooting Sports Program. This training is required to be a volunteer instructor in a county 4-H Shooting Sports Program.

We greatly appreciate the support that 4-H Volunteers provide to the 4-H Shooting Sports program and are happy to make this investment as we continue our partnership with the Indiana Department of Natural Resources. We also want to thank you for your commitment to serving Indiana youth through the 4-H Shooting Sports educational program!

 

Participant Information

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Telephone:
Cell Phone:
Email Address:
Gender: Male Female
Extension Educator:
County:

Discipline:
(Note:If you are not able to click a button or discipline, it is because the class is full at this time. All classes are subject to cancellation if minimums are not met.)
Archery
Pistol
Rifle
Shotgun
Muzzleloading
Outdoor Skills
Coordinator

 

Participant Status:
New
(Cost is $150.00, attend Friday night through Sunday afternoon)
Returning Option 1:
(Cost is $150.00 attend Sat. at 8 a.m. through Sunday afternoon)
Returning Option 2:
(Cost is $150.00, attend program Sat. 8 a.m. through Sunday afternoon, plus stay Friday night with Saturday breakfast included)
Returning Option 3: *New to 2017*
(Cost is $150.00, attend Friday through Sunday afternoon & attend Friday night's new session about Grant Writing and Program Development)

 

Can we share you name and address with other participants?
Yes No

 

Health Information

Do you require a lower bunk due to a medicalnecessity:
Yes No

 

Date of Birth (mm/dd/yyyy):

 

Physical Record of Participant:
Heart Condition: Yes No
Diabetes: Yes No
Respiratory: Yes No
Seizure: Yes No

 

List medicines allergic to:

 

List other allergies (i.e., food, dust, pollen, animals):

 

Date of most recent tetanus shot:

 

Any other medical record information that would be beneficial during the program or in an emergency:

 

List any activities the participant should avoid (i.e., swimming):

 

Person to contact in case of emergency
Name:
Address:
Home and/or Office Phone:

 

Name:
Address:
Home and/or Office Phone:

 

Registration Notes:

 

Payment Information is available after this form has been filled out and submitted.

Registration Steps:

  • 1. Fill out the registration form, and click 'Submit'
  • 2. Print the completed form
  • 3. Sign the printed copy and mail the registration with your Check or Money Order.
  •  

    If you have any questions please contact:

     

    Tim Beck
    I.D.N.R Law Enforcement
    P.O. Box 917
    Jasper, IN 47547

     

    Phone: (812) 482-3093
    Cell: (317) 694-7531
    Fax: (812) 482-3093
    E-mail: tbeck@dnr.in.gov

     

    Fees are subject to change after the Fall 2017 Workshop

     

    Optional: Additional information regarding National Archery in the Schools Program Certifications will be available at workshop. NRA certification is “No” longer available.

     

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