Nh 4-H Member Enrollment Form
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NH 4-H Member Enrollment Form
Club Code
Program Year 20
- 20
Member Code
Program year runs the same as school year, example 2009-2010
Entered by
New Enrollment
Re-Enrollment
Please check here if you were a cloverbud last year
Date
First Name
Middle Name
Youth Last Name
Alternate Name
County
Date of Birth
Member Cell #
Wireless Carrier
Home Phone #
Yes
Best Time to Call?
Permission to receive text msgs from 4-H?
No SMS Email
Primary Email Address
Secondary Email
Grade
Year in 4-H
Date First Enrolled in 4-H?
School
Level of Education
Active Army
Active Navy
Active Air Force
Active Marine Corps
Active Coast Guard
Military Family?
If Yes, please
Army Guard
Naval Reserve
Air Force Reserve
Marine Corps Reserve
Coast Guard Reserve
select your branch:
Army Reserve
Air Guard
Do You Want 4-H Mailings?
Prefer Email Newsletters?
Yes
No
Yes
No
I want the Extension office to be
aware of the following disability
or health consideration:
****************************************************************************************************************************************
Address Information
Street 1
Street 2
Actual town where your child lives if
Town
State
Zip Code
not the same as your mailing address:
****************************************************************************************************************************************
Ethnic:
Gender:
Residence:
Race:
City over 50,000
Farm
Hispanic
Asian
Female
White
Rural - Town under 10,000
Not Hispanic
Male
Alaskan/American Indian
Black
Town/City 10,000-50,000
Hawaiian/Pacific Island
Other
Suburb of City over 50,000
PARENTS Please Fill Out Information Below
Father/Guardian
Mother/Guardian
first & last name
first & last name
Primary Phone
Best time to Call?
Primary Phone
Best time to Call?
Work Phone
Ext.
Work Phone
Ext.
Cell #
OK to Text?
Yes
No
Cell #
OK to Text?
Yes
No
Email Address
Email Address
Mailing Address
Mailing Address
street, city, zip
street, city, zip
Is there a parent/guardian at a different location that wishes to receive information?
Full Name
Primary Phone
Mailing Address: street, city, zip
Continued on Next Page
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