Utah State University Cooperative Extension is an affirmative action/equal opportunity institution.
4-H YOUTH DEVELOPMENT ENROLLMENT SHEET
4-H is open to all youth without regard to race, gender, color, religion, national origin or disability.
YEAR: ____________________________
NAME OF CLUB ____________________________________________________________________________ CLUB CODE # (OFFICE USE ONLY) _________________________
By enrolling as a 4-H club, and adhering to the following criteria, we understand we will receive a 4-H charter which grants us the authority to appropriately use the 4-H name and
emblem. IRS and National 4-H Policies prohibit 4-H Family Clubs from inclusion under the 4-H General Exemption Number as a tax-exempt entity, and from raising funds for their specific club or members. Please check which type of club you are enrolling:
Regular 4-H Chartered Club – A club with 5 or more members from 3 or more
Family 4-H Club – A club with less than 5 members or from less than 3 families,
families, youth in leadership roles, and meets at least six times a year. youth in leadership roles, and meets at least six times a year.
Leader/Mentor Name
Please mark if Leader (L) or Assistant (A)
Complete Mailing Address
Street/po box, apt #
city, state, zip code
County use:
Yearsin 4-H
Background Check (Y/N)
Sex (M/F)
Ethnic Code
Spouse Name (if applicable)
Home Phone # Project Code
Email Address Cell Phone # (see back)
1.
H#
C#
2.
H#
C#
ETHNIC CODES:(Include all that apply) WH – White AI – American Indian/Alaskan HI – Hispanic AS – Asian BL – Black NH/PI – Native Hawaiian/Pacific Islander
YOUTH LEADERS: Assist the club leaders in leading the club or project meetings (must be grade 7-8 for Junior Leader; grade 9-12 for Teen Leader)
Member’s Name Complete Mailing Address
Street/po box, apt #
city, state, zip code
Youth
Leader
(Y/N)
Year
in
4-H
Date of
Birth
(M/D/Y)
Sex
(M/F)
Ethnic
Code
Grade
as of
Jan 1
Parent/Guardian Names Home Phone # Project
Code
Email Address (see back)
Cell Phone #
1. H#
C#
2. H#
C#
3. H#
C#
4.
H#
C#
5.
H#
C#
6. H#
C#
7. H#
C#
8. H#
C#
Return Enrollment Sheets, Code of Conduct, and Medical History Forms to USU Extension County Office as soon as club is organized. (Leaders should keep a copy of these
forms to have available when you are with club members.) Revised 2/08