Service-Learning and Citizenship Record

MD 4-H Youth Development

Service-Learning and Citizenship Record

This form may be used for 4-H members to track his or her service-learning hours. Service hours should include efforts to help others and to improve the community. You can be participating on behalf of a community, religious and or youth organization. It can be an individual effort or with a group such as school-based service-learning projects. Recognition may be through your local 4-H unit and may be attached to your 4-H Project Record.

Date / Activity / Audience / Activity Type * / Place of Service / Hours
Total / Hours Served:
Date / Activity / Audience / Activity Type * / Place of Service / Hours
Total / Hours Served:

It is the policy of the University of Maryland, Agricultural Experiment Station and Maryland Cooperative Extension, that no person shall be subjected to discrimination on the grounds of race, color, gender, religion, national origin, sexual orientation, age, marital or parental status or disability.

Activity Type * ( examples)

Community Improvement

Disaster Relief

Elderly Assistance

Natural Resources

Health and Fitness

Hunger and Homelessness

Literacy and Education

Public Safety and Violence Prevention

Youth Serving Youth

I verify that the above information is accurate.

4-H Member Signature Date of Submission

Address ______

County /Country Email Address ______Birth Date ______Age

Parent or Guardian Signature ______

1/12/03 DLB