Washington, DC 7-12, 2018 – Type your answers in the shaded First name Last Name Street City/State/Zip Code County Date of Birth Gender Years in 4-H Age January 1 this year Age today Home phone Parent’s work phone Your cell phone Your E-mail address Mother’s name Father’s name S M L XL XXL Name of 4-H Club T-shirt size Name of school Grade in school Do you have any food Do you have any allergies? special assistance Yes No Yes No needs? Special assistance Food allergy explanation needs explanation What career path do you plan to pursue? Ethnicity/race is requested for reporting purposes only to USDA. Hispanic White Black Asian Non-Hispanic Am. Indian/Alaskan Native Ethnicity Race Statement by 4-H Member I have personally prepared this report and certify that it accurately reflects my work and ideas. I agree to return to my club and county to implement a leadership project with the other National 4-H Conference delegates from Delaware. Date: ________________ Signature of 4-H Member: _________________________________________ Approval of this Report Date: ________________ Signature of Parent or Guardian: ____________________________________ Date: ________________ Signature of Local 4-H Leader (not a parent): __________________________ _______________________________ Date: ________________ Signature of County 4-H Agent: 4-H Project Summary List all major projects you have participated in as a 4-H member. – Include all projects and years of participation.
Washington, DC – 7-12, 2018 Type your answers in the shaded First name Last Name Street City/State/Zip Code County Date of Birth Gender Years in 4-H Age January 1 this year Age today Home phone Parent’s work phone Your cell phone Your E-mail address Mother’s name Father’s name Name of 4-H Club T-shirt size S M L XL XXL Name of school Grade in school Do you have any food allergies? Yes No Do you have any special assistance needs? Yes No Food allergy explanation Special assistance needs explanation What career path do you plan to pursue? Ethnicity/race is requested for reporting purposes only to USDA. Ethnicity Hispanic Non-Hispanic Race White Black Asian Am. Indian/Alaskan Native Statement by 4-H Member I have personally prepared this report and certify that it accurately reflects my work and ideas. I agree to return to my club and county to implement a leadership project with the other National 4-H Conference delegates from Delaware. Date: ________________ Signature of 4-H Member: _________________________________________ Approval of this Report Date: ________________ Signature of Parent or Guardian: ____________________________________ Date: ________________ Signature of Local 4-H Leader (not a parent): __________________________ Date: ________________ Signature of County 4-H Agent: _______________________________ 4-H Project Summary – List all major projects you have participated in as a 4-H member. Include all projects and years of participation.
2018-Conference-Application1.docx