NC 4-H Congress Registration
Please return registration and payment to 4-H office by June 23, 2017
Name: ______
Preferred Name (for nametag): ______
Emergency Contact Name & Phone Number: ______
4-H Age (as of January 1, 2017): ______Birthdate: ______
Years in 4-H: ______Are you the County’s Delegate? ______
Meal Choice (check one): Regular ______Vegetarian ______Other ______
T-Shirt Size (circle one):
Small Medium Large XL 2XL 3XL
Are you presenting during State Presentations? (circle one) YES NO
Are you graduating? (Circle One) YES NO
If yes, what college are you enrolling in and what is your declared major? ______
Are you participating in the AIRE Competition? (circle one) YES NO
**Applications are due to Union County 4-H by May 10, 2017 to be submitted to NC 4-H for judging**
Please list any 4-H related awards, you received from July 2016-June 2017 (i.e. State 4-H Project Awards, 4-H Ambassador Recognition, Community Service Awards, 2016 AIRE, Achievement Plan, Project Records, Portfolios, Presentations, Project Activity Winner – electric, horse, livestock, poultry, etc.):
Do you have any special requests?
Cost for Congress: / $100 (after $340 including lodging)Minus Scholarship Bucks/Awards:
Total Cost:
** Please make sure all enrollment and medical release information is up-to-date prior to leaving for Congress**
Make checks payable to: Union County 4-H
I give permission for ______to participate in NC 4-H Congress on July 29-August 1. I understand that Union County 4-H will depart from the Union County Agricultural Center on Friday, July 29 at 12 pm, and will arrive back Tuesday, August 1 at 7 pm (any delays or early arrivals will be notified by the Union County 4-H staff). I understand that the money and registration form is due by June 23, 2017, and any forms submitted later will be placed on a waiting list. I understand this is a firm deadline due to the increased interest in the activity.
Parent Signature: ______Date: ______
I hereby understand that North Carolina 4-H Youth Development does not accept any responsibility, custody, or liability for any of my personal property that I may bring to this event. I understand that it is my personal responsibility to safeguard such personal property of mine.
Youth Signature: ______Date: ______
RETURN TO: / UNION COUNTY 4-H YOUTH DEVELOPMENT3230-D PRESSON ROAD
MONROE, NC 28112