MemberEnrollment Form

About Your Family!

About You!

Family email:__________________________________ Last name:___________________________________ Best email to reach your parent or guardian

Mailing address:____________________________________________________________________________ Number and street name or P.O. Box

City:________________________________________ State:____________________ ZIP:_________________

Home phone:______________________________ Cell phone:______________________________________

Your name:____________________________________ Your email:___________________________________ First Name Last Name

Birthdate:______________________________________ Gender: Male Female Month / Day / Year

Your cell phone:________________________________________ Can we text you? Yes No

If yes, who is your cell provider? ______________________________________________________________ Verizon, Sprint, T-Mobile, etc.

Parent/Guardian 1:_______________________ First Name

_______________________ Last Name

Cell phone:_____________________________

Parent/Guardian 2:_______________________ First Name

_______________________ Last Name

Cell phone:_____________________________

Race: � White � Black or African American � American Indian or Alaskan Native � Native Hawaiian or Pacific Islander � Asian � Other combination � Prefer not to state

Residence: � Farm � Town under 10,000 and rural nonfarm � Town/city 10,000-50,000 and its suburbs � Suburb of city more than 50,000 � Central city more than 50,000

Ethnicity: Are you of Hispanic ethnicity? Yes No

APlaceforYou!

4-H Year: 2017-2018

Teacher:______________________School:_______________________Grade:________________________Club:_________________________

Online enrollment can be found at al.4honline.com

What would you like to do in 4-H?Animals & Agriculture the ones

you like Creative Arts the ones you like

Science & Technology the ones you like Environmental Education the ones

you like

Healthy Living the ones you like Outdoor Recreation the ones

you like

Leadership & Citizenship the ones you like Other the ones

you like

4HYD-2258 The Alabama Cooperative Extension System (Alabama A&M University and Auburn University) is an equal opportunity educator and employer. Everyone is welcome! © 2017 Alabama Cooperative Extension System. All rights reserved.