Members Evaluation Short Form

MARQUETTECOUNTY 4-H

MEMBERS’ EVALUATION SHORT FORM

Name Male Female

Address

(Street, Box)CityZip

Telephone Club

Grade in school Age as of Jan. 1 Years in 4-H

List projects in which you have been enrolled (recent ones first), and supply the requested information.

Project / Years enrolled / State your most important accomplishment in this project.

What 4-H projects have been most valuable to you and why?

List the activities you have been in (recent ones first), and supply the requested information.

Year / Activities / Leadership Roles in this Activity

What 4-H activities have been most valuable to you and why?

List leadership accomplishments:

Year / Leadership Accomplishment

Describe one leadership role and experience that you are particularly proud of that you have had on the club, county, or state level.

What goals do you still want to accomplish through your 4-H projects and activities?

List non 4-H activities (include church, school, and/or sports activities) and supply requested information.

Year / Activities / Leadership Roles in this Activity

Based upon your experiences in 4-H, what impact is 4-H having on your community? Could changes be made for 4-H to have an even greater impact?

Based upon your experiences in 4-H, what is an important concern of youth that you feel 4-H is helping youth deal with positively? Could changes be made for 4-H to help even more? How would your proposed change help?

Please complete the “M.E. Preference Form” on the last sheet of this document. It should be signed by your general or project leader and a parent/guardian.

M.E. PREFERENCE FORM

In what county sponsored trips have you previously participated?

Year

Of the trips offered this year, rank in order the one(s) you would be most interested in being considered for:

Wisconsin 4-H & Youth Conference (Grades 7-10)

Citizenship Washington Focus (Grades 10-12)

National 4-H Congress (Grades 10-12)

National 4-H Conference (Grades 10-12)

In addition to the above trips, you can also apply for the following. Check if you are interested:

4-H Key Award (Grades 11-13)

Parent/Guardian endorsement:

I feel that my child, , has stated the information in the M.E. Form accurately, and should be considered for selection by Marquette County 4-H for an award/trip.

Signed Date

General/Project Leader endorsement:

I feel confident that this 4-H member has stated the information in this M.E. Form accurately, and should be considered for selection by MarquetteCounty 4-H for an award/trip.

Signed Date

C:/…/memeval.short form

August 2012