Rock County 4-H Junior Awards Form

5th – 7th grades for the 2016-2017 school year

Filling out this packet will make you eligible for the following tripsawards:

Day Trip5th-7th grade

Members from the Rock County 4-H program will spend a day traveling and touring to see what Iowa, Wisconsin and Illinois has to offer. The location of this trip changes on a three year basis (2016–Chicago, 2017–Milwaukee, 2018–Dubuque). Participants will build teamwork skills, learn history close to home, and have an opportunity to meet other members from around the county. Total cost: approximately $60 per member (Member’s out-of-pocket cost: approximately $40)

4-H Space Camp 6th-8th grade

Members from across Wisconsin spend a weekend in April at the U.S. Space and Rocket Center in Huntsville, Alabama. They learn about the U.S. Space Program, ride simulators and work as a team to complete a simulated space mission. For 4-H members in 6th-8th grade (8th grade members complete the Resume Packet.) Total cost: approximately $525 per member. (Member’s out-of-pocket cost: approximately $350)

Outstanding Junior Member Award 5th-7th grade

The Rock County 4-H Leaders Council sponsors the Outstanding Junior Member award for Members in 5th – 7th grade that have shown a dedication to 4-H. Members will receive a plaque with their name engraved on it.

Challenge Award 7th-8th grade

Stuart and Marion Paul and their children provide engraved pens for members in 7th and 8th grade (8th grade members complete the Resume Packet) who are selected for their achievements and service to others.

UW-Extension provides equal opportunity in programming, including Title IX and ADA requirements. Requests for reasonable accommodations for disabilities or limitations should be made prior to the date of the program or activity for which it is needed. Please make such requests as early as possible by contacting the Rock County UW-Extension Office at 757-5696 so proper arrangements can be made.

Rock County 4-H Junior Awards Form

5th – 7th grades for the 2016-2017 school year

Print neatly or type form on computer to fill out. Do not add any extra lines or pages. Complete each section as described in the sections below. If you have questions, please call the UWEX office at 757-5696.

NAME & EDUCATIONFill out the appropriate lines

4-H PROJECT List the most recent projects you have been enrolled

SUMMARYin, the number of years, and if you are currently enrolled in them.(Name, Education & 4-H Project Summary = 5 points total)

4-H CLUB, List the 4-H activities you have participated in on the

COUNTY & club, regional, state, and national level and include the

OTHER ACTIVITY number of years involved.(10 points)

INVOLVEMENT

4-H COMMUNITYList or describe your community service within your

SERVICEclub and/or county and what you did.(10 points)

FAVORITE 4-HDescribe or write about your favorite 4-H

ACHIEVEMENTaccomplishment or leadership role from the 2015-2016

4-H year you are most proud of and why. (20 points)

NON 4-H ACTIVITIESList your activities outside of 4-H and the number of years

you have been involved. (5 points)

TOTAL POSSIBLE POINTS: 50 points

Check the trips and awards you are eligible and interested in winning. Once your form is complete, sign your name, have your parent/guardian sign and your 4-H club chair or an adult advisory member sign the bottom. Return your form to the UW-Extension Rock County office by September 16, 2016.

DO NOT ADD EXTRA LINES OR PAGES!!

Awards and trips will be based on the number of points scored and the member’s grade.

Revised 06-22-16

NAME: ______

STREET: ______

CITY, STATE, ZIP:______

PHONE NUMBER:______

EMAIL (If applicable):______

EDUCATIONSchool name: ______Grade (2016-2017): ______

4-H club name: ______# of years in 4-H: ______

4-H Projects / # Years
Enrolled / Currently Enrolled
(Yes/No)

4-H PROJECT

SUMMARY

4-H Activities
Ex: Camp, Bowling Bonanza, Club Fundraiser / # Years

4-H CLUB,

COUNTY,

& OTHER 4-H

ACTIVITY

INVOLVEMENT

Community Service & Description
Ex: Youth Service Day – raked leaves / # Years

4-H COMMUNITY

SERVICE

Describe the 4-H accomplishment or leadership role
you are most proud of from the 2015-2016 year

FAVORITE 4-H ACHIEVEMENT

Other Activities
Ex: School, Church, Sports, etc. / # Years

NON 4-H ACTIVITIES

Please ChECK the trips and awards you are interested in winning:

Space Camp (6th – 8th grade)** Day Trip (5th – 7th grade)

Challenge Award (7th – 8th grade) ** Outstanding Junior Member (5th – 7th grade)**8th grade selected from Resume process

______

4-H member signatureParent/Guardian SignatureClub Chair or Adult Advisory Signature