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.
