Kansas 4-H Enrollment Form
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2Kansas 4-H Enrollment Form
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Today’s Date ____/____/____
Member _____________________________________________________ County _________________________________
First Name
Last Name
MI
Birthdate _______________ Phone _______________________________ ________________________________________
Home – Landline
Member’s Mobile
Member Email _________________________________________________________ Years in 4-H ____________________
School __________________________________________________________________ Grade Level ____________________
4-H Club _______________________
Military Family? If so, please check
Do you have any special needs?
Yes No
Active Duty; Branch _____________
Club Officer ____________________
If yes, please provide details on your
National Guard; Branch __________
2nd Club (if applicable)
Kansas 4-H Participation Form.
______________________________
Reserves; Branch _______________
Ethnicity: (Check One)
Hispanic Non-Hispanic
4-H Head of Household
Gender Female Male
Parent/Guardian ____________________________________________________
First Name
Last Name
Place of Residence: (Check one)
Email ______________________________________________________________
Farm
___________________________________________________________________
Rural or Town under 10,000
Home Phone
Mobile Phone
Work Phone
Town or City 10,000-50,000
Address ___________________________________________________________
Suburb of City over 50,000
City over 50,000
___________________________________________________________________
Kansas
City
State
Zip
Race: (Check all that apply)
Member resides at this address
Send local 4-H newsletter by email
White
Black
Parents/
American Indian/Alaska Native
Guardians _________________________________________________________
Asian
First Names
Last Name
Hawaiian/Pacific Islander
Email ______________________________________________________________
___________________________________________________________________
I wish to receive 4-H information via
Home Phone
Mobile Phone
Work Phone
text message
Address ___________________________________________________________
______________________________
___________________________________________________________________
Kansas
Mobile number
City
State
Zip
______________________________
Member resides at this address
Send local 4-H newsletter by email
Cellular/Wireless Provider
To keep 4-H enrollment information secure and to improve data management and reporting requirements, K-State Research
and Extension will maintain 4-H enrollment information in an on-line database. This system, known as Access 4-H, will be man-
aged on a certified secure server maintained by National 4-H Council.
Authorization
I understand all enrollment information may be stored in Access 4-H or a similar system.
_______________________________________________________________________________________________________
4-H Member Signature
Parent or Guardian Signature
Date
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