Florida 4-H Youth Enrollment Form
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1Florida 4-H Youth Enrollment Form
Directions: After you have contacted your County 4-H Agent and chosen a local 4-H Program for your child to be a part of, you will need to complete
a 4-H Youth Enrollment Form and a Florida 4-H Participation Form for Youth and Adults. These forms can be completed online by a parent or a
legal guardian at . If parents or guardians do not have access to a computer, they may complete the Enrollment and
Participation Forms and turn both into their County 4-H Agent or 4-H Club Leader. You will be contacted by your County Extension Office when your
forms have been entered in 4HOnline.
Family Profile Information
Family Last Name:_______________________ Family E-mail:________________________ ________Primary Phone:_( _______ ) _______________
Address: _______________________________________________ City:________________________________ Zip:________________________
Correspondence Preference:
E-mail
Mail 4-H County: _____________________________ Primary 4-H Club:__________________________ _
Member Profile Information
Member E-mail (if different from Family E-mail):___________________________________
First Name:
________ Middle Name:
__
Last Name:
_______
Preferred Name:
________ ______ Mailing Address (if different from Family Address):________
_______________________
City:
State:
Zip Code:
Birth Date:
/
/
4-H Age (as of September 1, 2016):________ Number of years as a 4-H member, including current year:_____________
Parent/Guardian 1: First Name:
___________
Last Name:
________________
Work Phone: (
)
Cell Phone: (
)
________________________________________
Parent/Guardian 2: First Name:
___________ Last Name:
________________
Work Phone: (
)
Cell Phone: (
)
________________________________
Emergency Contact (Other than Parents/Guardians) First and Last Name:
_____
________________________________
Emergency Contact Phone: (
)
_ Emergency Contact Relationship
________________________
Is the member a youth volunteer?*
Yes
No
* If the member is a youth volunteer, a UF/IFAS Employee may contact you with further enrollment instructions.
Ethnicity: Are you of Hispanic ethnicity?
Yes
No
I prefer not to give my race.
Race:
White
Black
Asian
American Indian or Alaskan
Native Hawaiian or Pacific Islander
Gender:
Male
Female
Residence:
Farm
Town Under 10,000 or rural non-farm
Town/city 10,000-50,000
Suburb of city more than 50,000
Central city more than 50,000
Parent or Sibling Serving in the Military:
The member has a parent serving in the military.
The member has a sibling serving in the military.
A Family Member is in:
Air Force
Army
Coast Guard
DOD Civilian
Navy
Marines
Branch:
Active Duty
National Guard
Reserves
Grade: _________________ School:
_________________ School is in my 4-H County?
Yes
No
In 4-H in a county different from the County I Live in. County I Live In :_____________________________________________
In 4-H in 2 counties My 2nd 4-H County:________________________Club___________________Project_____________________Year______
Years in
Project Book Title Needed
Program Fees if Applicable:
Project Title
Project
Club Fee/Dues Paid $
Purchase of Project Books
Due $
Paid $
(Bal. Due: $
)
Total Amount Paid: $
Paid by Check
Check #
For County Office Use Only: Date forms received in County Office___________________
Paid by Cash
Date forms entered into 4HOnline Database _____________________________________
Revised July 1, 2016 for the 2016-2017 4-H Year
A completed Florida 4-H Participation Form for Youth and Adults is required with this form.
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