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4-H Member Enrollment Form

Collects 4-H member information, health, permissions, and activity choices.

Member Name (first & last)*

School Name*

Grade*

YS, YM, YL, YXL, AS, AM, AL, AXL, AXXL, AXXXL

T-Shirt*

Family Name (last name)*

Family Email*

Family Phone*

Family Address (mailing address, CITY, state)*

mailing address, city & zip code

First Name (Member)*

Last Name (Member)*

Preferred Name (Optional)

Birthdate*

//

Previous Years In 4-H*

Biological Sex*

AMale

BFemale

Residence Type*

AFarm

BTown <10,000 Or Rural Non-Farm

CTown/City/Suburb 10,000-50,000

DCity/Suburb >50,000

ECity-Central >50,000

Hispanic Or Latino*

AYes

BNo

Race*

AAmerican Indian

BAsian

CBlack

DNative Hawaiian Or Pacific Islander

EWhite

FPrefer Not To Say

GNot Listed

Parent/Guardian Info

Last Name*

First Name*

Phone (Emergency Contact)*

May Release Personal Info (Contact 1)*

AYes

BNo

Last Name

First Name

Phone

May Release Personal Info (Contact 2)

AYes

BNo

Emergency Contact

Name (Emergency Contact 2)*

Relationship*

Phone*

May Release Personal Info (Emergency Contact)*

AYes

BNo

Pick Up Release Information

Name Of First Person

Relationship To 4-H Member (First Person)

Phone (First Person)

Name Of Second Person

Relationship To 4-H Member (Second Person)

Phone (Second Person)

Military Service (if none, skip this section)

Relationship To Member Serving

Branch Of Service

Active Duty

AActive Duty

National Guard

ANational Guard

Reserves

AReserves

Other

AOther

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