4-H Enrollment Form

University of Nebraska Cooperative Extension in Douglas and Sarpy Counties

Enrollment Form

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2010 4-H Youth Enrollment Form
Enrollment Fee: $10
Submit completed form before June 10, 2010
Items marked with a red asterisk * are required fields

Primary Club*
Other 4-H Clubs I belong to are

Last Name*
First Name*
M.I.*
4-H Age (as of 1-1-10)*
Date of Birth*
Address*
City*
Zip*
Phone Number*
Other Phone Number
Name of School*
Grade in School*
Years in 4-H (include this year)*
E-mail Address*

Are you a member of an active/reserve or retire military family?

Yes No

Check One*

Club Member

Clover Kid

Independent Member

Check One*

New Enrollment

Re-enrollment

Gender*	Male	Female
Junior Leader*	Yes	No
Check One*	pay on-line by credit card	pay by mail

Ethnicity
(check one)*

Hispanic or Latino

Not Hispanic or Latino

Race/Ethnic*

White

Black or African American

(Check all that apply)	Native Hawaiian or other Pacific Islander
	American Indian or Alaskan Native	Asian


Residence*	Farm/Ranch	Town under 10,000 & rural non-farm

(Check one)	City, 10,000-50,000
	Suburb of City >50,000	City over 50,000

County of Residence* (Check one)

Douglas

Sarpy

Horse project member ($1.00 fee)	Insurance for Horse - $1.00
We assure reasonable accommodations under the Americans with Disabilities Act. For assistance, contact your local Cooperative Extension office no later that June 15 of the current 4-H year.

Parent/Guardian Information:
Parent/Guardian 1 Name*
Address*
City*
State*
Zip*
E-mail Address*
Occupation
Phone Number*
Alt. Phone Number
Send Mailings*	Yes No
Permission*	Yes No I give permission to use my child's name/photograph in publications, ads, news articles, or websites pertaining to 4-H.
Parent/Guardian 2 Name
Address
City
State
Zip
E-mail Address
Occupation
Phone Number
Alt. Phone Number
Send Mailings	Yes No

2010 Douglas/Sarpy County 4-H Project List * Choose a project(s) from the options listed below: (check at least one project)
Animal Science
	Beef
	Dairy Cattle
	Sheep
	Swine
	Goat
	Horse
	Poultry
	Rabbit
	Cat
	Dog
	Companion Animal
	Veterinary Services

Leadership & Citizenship
	Leadership
	Citizenship

Communication & Expressive Arts
	Communication
	Theater Arts
	Photography

Science & Technology
	Aerospace
	Computers
	Electricity
	4 Wheelin'
	Robotics
	Small Engines
	Woodworking
	Welding

Healthy Lifestyle Education
	Food and Nutrition
	Physical Fitness
	Lifetime Sports
	Safety
	Health

Plant Science
	Crop Production
	Horticulture

Environmental Education & Earth Sciences
	Conservation
	Entomology
	Forestry
	Range

Consumer & Family Science
	Human Development
	Sewing for Fun
	Clothing 1
	Clothing 2
	Sewing for You
	Tailoring
	Decorate Your Duds
	Knitting
	Crocheting
	Quilt Quest
	Consumer Management
	Entrepreneurship
	Heritage
	Home Environment

Clover Kids
	Citizenship
	Communication & Expressive Arts
	Food & Nutrition
	Safety
	Home Environment
	Exploring Animals
	Exploring Outdoors

Please only click the submit button once, to prevent sending duplicate registrations.

Purpose of 4-H: 4-H is a community of young people across America learning leadership, citizenship, and life skills. 4-H is a formal component of the University of Nebraska- Lincoln Extension youth education effort. Extension will provide support to 4-H clubs, members, and volunteers to help them provide positive educational experiences. In return, 4- H clubs, members and volunteers are accountable to Extension for their activities and finances. Use the Clover: The 4-H Name & Emblem are protected under the United States Code 18 USC707. Appropriate use of the 4-H Name & Emblem is permitted by a 4-H member or volunteer once the 4-H club is chartered by National 4-H Headquarters at the Cooperative State Research, Education and Extension Service (CSREES) within the United States Department of Agriculture. For more information about use of the 4-H Name & Emblem, contact your local Extension office or visit the 4-H website. Non-Discrimination Statement: Nebraska 4-H abides by the non-discrimination policies of the University of Nebraska-Lincoln and the United States Department of Agriculture.

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University of Nebraska Extension   Southeast Research and Extension Center
Extended Education & Outreach   Institute of Agriculture & Natural Resources
University of Nebraska-Lincoln   University of Nebraska   United States Department of Agriculture
Cooperative State Research, Education, and Extension Service

University of Nebraska Extension educational programs abide with the nondiscrimination policies
of the University of Nebraska-Lincoln and the United States Department of Agriculture.

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