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Maine 4-H Youth Development Volunteer Application

Thank you for your interest in 4-H and Cooperative Extension. Please complete this application and return it to your University of Maine Cooperative Extension county office.

Name: _____________________________________________________________________________________

^{Last
First
Middle}

Mailing Address: ___________________________________________________________________________________

                           ^{Street
City
State                                Zip}

Phone Day: _________________________________________ Best time to call: ________________________

Evening: ____________________________________________ Best time to call: _______________________

Were you in 4-H? _____________________________________

If so, where_________________________

^County/State

Have you ever been a 4-H leader? ____ Yes ____ No If yes how many years and when? ______________________

Where?____________________________________________________________________________________

^{City
County
State}

Please use a separate sheet of paper to explain why you are interested in a 4-H Volunteer position.

Do you prefer to work directly with: ( ) youth ( ) adults ( ) both

If you prefer to work with youth, what grade level(s) do you prefer?

( ) Pre-school ( ) Intermediate Grades: 6, 7, 8

( ) Primary Grades: 1, 2 ( ) Senior Grades: 9, 10, 11, 12

( ) Junior Grades: 3, 4, 5

Previous work or volunteer experience: (List current or most recent experience first.)

Employer or Organization Position Title or Volunteer Role Year

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Skills, Training, Education _______________________________________________________________________

______________________________________________________________________________________________

Hobbies and interests ____________________________________________________________________________

______________________________________________________________________________________________

How did you hear about the 4-H volunteer program? ___________________________________________________

______________________________________________________________________________________________

References: List two persons not related to you who have definite knowledge of your qualifications. Include complete addresses.

Name: ___________________________________________ Day Phone: ___________________________________

Address: _______________________________________________________________________________________

             ^{Street
City                                                                  St
                    Zip}

Name: ___________________________________________ Day Phone: ___________________________________

Address: _______________________________________________________________________________________

                     ^{Street
City                                                                  St
                    Zip}

May we contact other references suggested to us in the course of contacting the references listed above? __________

Please note: Information received from any references will be considered as part of your application.

Have you ever been convicted of any crime other than a minor traffic violation?

If yes, please describe.

I authorize contact of listed references. I understand that misrepresentation or omission of facts requested is cause for non-appointment or termination as a Cooperative Extension volunteer. I agree to abide by the expectations of Cooperative Extension and to fulfill the volunteer responsibilities to the best of my ability.

Volunteer Signature Date

Published and distributed in furtherance of Acts of Congress on 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.

If you are a person with a disability and will need any accommodations to participate in this program, please call the county Extension office to discuss your needs. Please contact us at least 10 days prior to the event to assure the fullest possible attention to your needs.

The University of Maine, U.S. Department of Agriculture, and local governments cooperating. 12/06/07