Individual Enrollment Form

Illinois 4-H Individual Enrollment Form

Jackson County

This form is primarily for new participants in this group, but may be used by those re-enrolling if a preprinted Illinois 4-H Individual Re-Enrollment Form is not available. Each youth participant must enroll in at least 1 project yearly. See project list if attached or check with group’s leader to ensure project enrollment.

o New o Member

o Re-enroll o Youth Leader

Group Name______ o Adult Leader

First Name: MI Last Name: Sex: Yrs in 4-H:

o Female (including this year)

______o Male _____

Parent’s First Name Parent’s Last Name Youth/Parent Email Address (optional):

______

Complete Street and Mailing Address (for US mail and/or UPS delivery) Zip code:

______-______

City State County of Residence Home Phone: Alternate Phone

______(_____)_____-_____ (_____)_____-_____

Ethnicity: Date of Birth Grade (KI-12, PO (post-high school)

Hispanic or Latino o Yes o No ______/_____/______NO (not in school))

Race: (select one or more) Residence:

o American Indian or Alaskan Native o Farm (where income is earned farming)

o Asian o Rural/Small Town (under 10,000)

o Black or African American o Medium Town (10,000-50,000)

o Native Hawaiian or Pacific Islander o Suburb of one of the cities above

o White o City (includes Bloomington-Normal, C-U, Chicago, Decatur, Joliet,

Peoria, Rockford, Rock Island/Moline, Springfield, or East St. Louis)

Parents or Adult Participants:

I would like information on the Illinois 4-H Foundation and how it supports the 4-H program. o Yes o No

I would like information on the county-level Foundation and how it supports the 4-H program. o Yes o No

I grant the 4-H Youth Program, University of Illinois Extension, the permission to disclose my (or my child's) identity and to reproduce and distribute videotapes, films, photographs, and transparencies of me (or my child) and sound recordings arising out of documenting 4-H youth programs. o Yes o No

4-H Youth Guidelines: All youth who participate in Illinois 4-H Youth Development programs, which are planned, conducted, and supervised by University of Illinois Extension, are responsible for their own conduct. Youth participating in 4-H programs are expected to demonstrate the character traits of trustworthiness, respect, responsibility, fairness, caring, and citizenship. Specifically, 4-H youth are expected to abide by the following behavior guidelines.
1.  Be courteous and respect others.
2.  Obey all rules established by the University of Illinois Extension 4-H Youth Development program and those of the local club/group as well as local and state laws.
3.  Treat all people fairly and animals humanely.
4.  Respect the property of others.
5.  Respect the authority of adult or youth volunteers, paid Extension staff, and others in leadership roles.
6.  Use appropriate language and wear acceptable clothing at 4-H activities and events.
7.  Show kindness to others and give assistance when needed.
8.  Be honest and honor commitments.
9.  Strive for personal best and keep trying to improve.
10.  Accept responsibility for personal choices.
We understand and accept the responsibility for following the 4-H Youth Behavior Guidelines. We further understand that failure to do so may result in disciplinary action and forfeiture of participation privileges.

______

Signature of Participant Signature of Parent/Guardian Date

______

Issued in furtherance of Cooperative Extension Work, Acts of May and June 30, 1914, in cooperation with the U.S. Department of Agriculture, Dennis Campion, Director, University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension provides equal opportunities in programs and employment. The 4-H Name and Emblem are Protected Under 18 U.S.C. 707.

revised 8/2004