North Carolina Cooperative Extension Service
Name______
County______
District ______
READ CAREFULLY: This application should be filled out in detail. Please print or type.
Please rank the 4-H Activity(ies) 1st thru 3rd in the ( ) for National 4-H Congress, Conference and ILC Only.
Three (3) copies of the application & resume should be submitted when applying for any of the trips. The application and resume should be in a folder.
Mail to: Shannon McCollum Extension 4-H Associate, Box 7606 NCSU Raleigh, NC
27695-7606. Due postmarked May 15
( ) National 4-H Congress - November. Interview at NC 4-H Congress - Spending money is needed.
( ) National 4-H Conference - - Interview at NC
4-HCongress. The actual cost to the 4-H’er is $250 plus spending money.
( ) International Leadership Conference – Summer: Interview at NC 4-H Congress - Approximate cost to the
4-H’ers depends on the location. All travel costs are paid
by the 4-H’er.
The North Carolina 4-H Program is an equal opportunity program.
You may request any needed accommodations to participate in the application or interview process.
Please limit your answers to the space provided.
** NATIONAL CONGRESS APPLICANTS ONLY: Please rank the curriculum categories in which you want to compete by placing a rank order in the box. Example: Citizenship & Civic Education = 1, Communications Arts = 2, etc...You are only allowed to choose 3 top curriculum category choices. Under Animal Science, please circle if you are applying for Beef, Dairy, Horse, Poultry, Sheep or Swine.
NATIONAL 4-H CONFERENCE APPLICANTS: Do not select curriculum Categories.
Personal Information
(Print) Full Name
Last First Middle
Present Address
Number and Street or Route
City State Zip Code
Social Security Number Telephone Number ( )
Are you between 14 and 18 years old as of January 1? Yes No Age
Date of Birth
County
E-Mail Address if applicable
Education
Name of school attending (specify if home school):
List educational honors and accomplishments:
4-H Youth Development History
4-H Projects/Activities/Events in which you have participated. Please list the title and number of years of participation:
Please describe two (2) significant 4-H experiences that have impacted your future goals
List 4-H Honors and Accomplishments:
Why are you submitting an application for this Leadership Opportunity
2
4-H Volunteer Leadership History
Type of Leadership Dates Involved
Duties and Responsibilities
Describe skills you utilized in this role
Type of Leadership Dates Involved
Duties and Responsibilities
Describe skills you utilized in this role
Type of LeadershipDates Involved
Duties and Responsibilities
Describe skills you utilized in this role
3
Citizenship/Community Involvement History
Type of Community Involvement Dates Involved
Duties and Responsibilities
Describe skills you utilized in this role
Type of Community Involvement Dates Involved
Duties and Responsibilities
Describe skills you utilized in this role
Type of Community Involvement Dates Involved
Duties and Responsibilities
Describe skills you utilized in this role
Certification Statement:
I certify that the information on this application is accurate and complete.
Should I be selected to represent North Carolina at a National Event, I promise to abide by all rules.
______
4-H Applicant signature Date Parents/Guardian’s signature Date Agent’s Signature Date
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