4-H Leader Enrollment

University of Nebraska Cooperative Extension in Douglas and Sarpy Counties

Leader Enrollment Form

- return to 4-H home page -

Leader Enrollment
Items marked with a red asterisk * are required fields

Primary Club*:

Are you going to be the Leader or one of the Co-Leaders of this club?
Organizational Leader (only 1 per club)
Assistant Leader (check one)	Project Activity Resources
Are you accepting new members to your club?	yes no
Are you willing to be a mentor to new club leaders? (answering questions over the phone)	yes no

Other 4-H Clubs I Belong To:

Last Name*
First Name*
M.I.*
Address*
City*
State*
Zip*
Phone Number*
Work Number
Check One*	Male Female
E-mail Address*

Ethnicity (check one)* Hispanic or Latino Not Hispanic or Latino

Race*
(Check all that apply) White Black or African American Native Hawaiian or
other Pacific Islander

American Indian/Alaskan Asian

Residence*
(Check one) Farm/Ranch Town under 10,000 & rural non-farm

City,10,000-50,000 Suburb of City >50,000 City over 50,000

Years in 4-H (include this year)*

4-H Alumni? Yes No Year Screened:

What is the main focus of your club?

Traditional

Clover Kids

Community Club

Independent

Family Club (yours only)

Dog

Horse

Rabbit

Science Engineering & Technology

other :

Photo Release* Yes No
I give permission to use my name or name/photograph in publications, ads, news articles, or websites pertaining to 4-H.

This 4-H Club/Group that I am a leader of abides by the nondiscrimination policies of the University of Nebraska-Lincoln and the United State Department of Agriculture. The 4-H Club/Group request authorization to use the 4-H Name and emblem.

Insurance: Insurance - $1.00 Insurance for Horse - $2.00

Print the Volunteer Screening Form form and return to the address listed.

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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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