NEW MEMBER 4-H REGISTRATION   YEAR_____ (RETURN TOP TO OFFICE)

Name__________________________________________________________ Address________________________________________________________
City_______________ TWP_________________ Zip___________________ Phone_______________   Circle County:   Stark / Summit
Parent/Guardian Names___________________________________________
Yth Birthdate __/__/__ Age as of Jan 1_______ Grade in School _____________ School_____________________________Years in 4-H (include this year) _____ Gender(M/F)____
Race____ (W-White B-Black I-American Indian/Alaskan H-Hispanic/Spanish American A-Asian, Oriental)
Residence____ (F-Farm R-Town under 10,000 T-Towns/Cities 10,000-50,000 C-Central cities over 50,000)
Club Name___________________________________ Office Held _____________________
List membership in other club____________________________________________________
Project #(additional projects back)  Project Name Years in Project

Signatures:   4-Her's____________________________ Parent's__________________________
Advisor's___________________________
 
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NEW MEMBER 4-H REGISTRATION    YEAR_____ (ADVISOR-KEEP COPY)

Name___________________________________________________________
Address_________________________________________________________
City_______________ TWP_________________ Zip____________________
Phone_______________          Circle County:   Stark /  Summit
Parent/Guardian Names____________________________________________
Yth Birthdate __/__/__  Age as of Jan 1_______ Grade in School ______________
School_____________________________ Years in 4-H(include this year)____ Gender(M/F)____
Race____ (W-White B-Black I-American Indian/Alaskan H-Hispanic/Spanish American A-Asian, Oriental)
Residence____ (F-Farm R-Town under 10,000 T-Towns/Cities 10,000-50,000 C-Central cities over 50,000)
Club Name___________________________________ Office Held _____________________
List membership in other club____________________________________________________
Project #(additional projects back) Project Name Years in Project
 
 
Signatures:   4-Her's____________________________ Parent's__________________________
Advisor's___________________________
 
 
 Please print off, complete and return to:
    The Ohio State University Extension
    Stark & Summit Counties
    5119 Lauby Road
    North Canton, Ohio 44720
    330-497-1611 voice
    330-497-2807 Fax
 
 
 
 
 

Program Evaluation & Measurement Resource Site
Stark & Summit Counties 4-H Youth Program
The Ohio State University Extension
Stark & Summit Counties
 
David C. Crawford, Extension Agent; 4-H/Youth Development
Joyce Hager, 4-H Secretary
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