Maine 4-H Member Enrollment Form

MAINE 4-H MEMBER ENROLLMENT

Last Name: _____________________________ First: _____________________________ MI: ______

Mailing Address:________________________________________________________________________

City: ______________________________________________ State: ______________ Zip: ___________

Home Phone: ( ) __________________________ Alternate Phone: ( )___________________

Birth date: _________________________________ Gender: Male Female

Email address: ______________________________________________________________________

Parent/Guardian names: ___________________________________ Work Phone ____________________

Parent/Guardian email address: ______________________________Work E-mail:___________________

Years in 4-H: ____ Grade: ______ School Name: __________________ or (√) if Home Schooled:

(Including this Year)

Please provide us with this optional data so that we may report to our federal partners.

Racial Groups: (check all that apply):

White

Black or African American

American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Asian

Hispanic Ethnicity: (check one):

Yes – Hispanic or Latino Ethnicity OR No -- Not Hispanic or Latino Ethnicity

Residence (Check one):

Farm Rural non-farm or town less than 10,000 Town/City 10,000 to 50,000

Suburb City over 50,000

Mark 4-H Projects you are taking on the back of this form.

Name of Primary 4-H Club 1: __________________ Club 2: ________________ Club 3:______________

_____________________________ _______________________ _____________________________

Participant Signature Parent/Guardian Signature 4-H Volunteer/Leader Signature

Published and distributed in furtherance of Acts of Congress of May 8 and June 30, 1914, by the University of Maine Cooperative Extension, the Land Grant University of the state of Maine and the U.S. Department of Agriculture cooperating. Cooperative Extension and other agencies of the U.S.D.A. provide equal opportunities in programs and employment.

In complying with the letter and spirit of applicable laws and in pursuing its own goals of diversity, the University of Maine System shall not discriminate on the grounds of race, color, religion, sex, sexual orientation, national origin or citizenship status, age, disability, marital or veterans status in employment, education, and all other areas of the University. The University provides reasonable accommodations to qualified individuals with disabilities upon request. Questions and complaints about discrimination in any area of the University should be directed to the Executive Director of Equal Opportunity, The University of Maine, Room 101, 5754 North Stevens Hall, Orono, ME 04469-5754, telephone (207) 581-1226 (voice and TDD).

Persons with disabilities, who need accommodations to participate in our programs, please call Angela Martin at (207) 581-3739, at least 10 days in advance