Author: OP

Kansas 4-H Enrollment Form 2016/17

Please Print
Member_______________________________________________________________ Club/Group_____________________________ Email___________________________________________
First Last MI
Mailing Address ______________________________________________________________________________ Phone # ________________________________________________________
Street City ST Zip Home Cell*

Today’s Date ___/___/_____

Place of Residence (Check One) r Farm r Rural or Town under 10,000 r Suburbs of City over 50,000
Ethnicity (First Check One) r Hispanic r Non-Hispanic Gender r Male r Female
Race: (Then Check All that Apply) r White r Black r American Indian/Alaska Native r Asian r Hawaiian/Pacific Islander
Do you have special needs? r Yes r No If yes, please provide details on attached Kansas 4-H Participation Form.

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To help us serve you better, please check your preference for receiving 4-H information. We can send via e-mail, text, mail or both. Also, help us know your project needs by checking if you would like project information below. Some project books have a small fee and require us to order from National 4-H Council. Contact us for details. Let us know how we can assist you with your 4-H project work.

To help us serve you better, please check your preference for receiving 4-H information. We can send via e-mail, text, mail or both. Also, help us know your project needs by checking if you would like project information below. Some project books have a small fee and require us to order from National 4-H Council. Contact us for details. Let us know how we can assist you with your 4-H project work.

Complete parent/guardian information below for each parent/guardian:

Date of Birth _________ Age on Jan. 1, 2017 ______________
Year I first enrolled in 4-H ___________This is my ________ year in 4-H.
School _________________________________________________
Grade _________________________________________________
r *Text messaging (list cell phone carrier) ___________________________
(To honor personal privacy this information will be used by Extension Staff only and kept confidential.)
r Use family e-mail address only for all 4-H contacts.
Family E-mail ______________________________________
r 4-Her prefers mail/our family prefers mail
r 4-Her prefers e-mail information
r Use personal e-mail for project information/events/mail newsletter
r Other _____________________ ________________
r Military Family/Branch ______________________________________

Mother _______________________________________________________________
Address_______________________________________________________________
Relationship _______________Legal Guardian Y N Send Mailings Y N
Phone #’s _____________________________________________________________
Home Work Cell
Email ____________________________ Occupation __________________________

Father ________________________________________________________________
Address_______________________________________________________________
Relationship _______________Legal Guardian Y N Send Mailings Y N
Phone #’s _____________________________________________________________
Home Work Cell
Email ____________________________ Occupation __________________________

Complete emergency contact information below (in addition to the parent/guardian information above. For emergencies, parents will always be first.

Name___________________________________________________________________________ Relationship _____________________________ 4-H Mailings Y N
Address ______________________________________________ Phone #s __________________________________________________________________________________
Home Work Cell

Transfer the project code and the name of the project enrolled to the front of the card. Complete your project information below as shown in the example.

Project Code & Project	Info	Years in Project	Project Code & Project	Info	Years in Project	Project Code & Project	Info	Years in Project
Example: VA204 Jewelry		3

4-H Project List
Select the projects that you will enroll in by writing the project and the project number on the front of the card. If this is your first year in 4-H we advise you not to enroll in more than one or two projects. Other 4-Hers should consider your time commitments carefully before you enroll in more than four projects. PLEASE NOTE: For projects designated as Beginner (7-8), Junior (9-11), Intermediate (12-13), Senior (14 and older) skill mastery ages are general guidelines. When ordering project curriculum, the age and experience of the 4-H member should be considered. The Kansas 4-H Project Selection Guide, at www.bookstore.ksre.ksu.edu/pubs/4H1065.pdf can assist in making project selections. For more information check with your club leader, Extension Agents www.atchison.ksu.edu or Kansas 4-H web www.Kansas4-H.org.

Beef
r BF100 Beef Bucket Calf
r BF200 Market Beef
r BF201 Breeding Beef
Citizenship
r CS100 All Phases
Clothing and Textiles
r CT100 Construction BG
r CT200 Construction JR
r CT300 Construction INTR
r CT400 Construction SR
r CT101 Buymanship BG
r CT201 Buymanship JR
r CT301 Buymanship INTR
r CT401 Buymanship SR
Communications
r CM100 All Phases
r CM301 Public Speaking
Consumer Studies
r FS100 Consumer Skills
r FS101 Child Development
r FS102 Family Studies
r SD101 Financial Champions
Dairy Cattle +
r DC100 Dairy Bucket Calf
r DC200 Dairy Heifer
r DC300 Dairy Cow
Dog Care & Training
r DG100 Showmanship
r DG101 Obedience
r DG102 Agility
r DG103 Rally Obedience
Energy Management
r EL100 Electric/Electronics
r SE100 Small Engines
r EM101 Power of the Wind
Environmental Sciences
r EN100 Entomology/Butterfly
r GE100 Geology
r SD101 Beekeeping
Fiber Arts
r FA101 Crochet
r FA102 Knitting
r FA103 Needle Arts
r FA104 Patchwork/Quilting
r FA105 Rug Making
r FA106 Spinning
r FA107 Weaving
r FA108 Ethnic Arts
r FA109 Macramé
Foods and Nutrition
r FN100 Beginner
r FN200 Junior
r FN300 Intermediate
r FN400 Senior
r FN101 Breads
r FN102 Food Preservation
r FN103 Cake Decorating
Goats (Dairy) +
r GD100 All Phases
Goats (Meat)
r GM100 All Phases
Health and Wellness
r HL100 Bicycle
r HL101 Health
r HL102 Outdoor Adventure
r HL103 Recreation
r HL104 Lifetime Fitness
Home Environment*
r HE100 All Phases
Horse
r HO100 All Phases
Leadership
r LS100 All Phases
r LS300 Active Leadership
Performing Arts
r PA100 All Phases
Pets
r PT100 Pets-All Phases
r PT101 Cats-All Phases
Photography
r PH100 Beginning Photography
r PH200 Junior Photography
r PH300 Intermediate Photography
r PH400 Senior Photography
Plant Science
r PL100 Horticulture/Vegetables
r PL101 Field Crops
r PL102 Flowers
r FO100 Forestry
Poultry
r PO100 All Phases
Rabbits
r RA100 All Phases
Reading
r RD100 All Phases
Self-Determined
r SD100 All Other
r SD102 Ham Radio
Sheep
r SH100 Market Lamb
r SH200 Breeding Sheep
Shooting Sports
r SS200 Archery
Space Tech
r ST100 Aerospace/Rocketry
r ST101 Astronomy
r ST102 Robotics
r SD105 Geospatial GPS/GIS
Swine
r SW100 Market Swine
r SW200 Breeding Swine
Visual Arts and Crafts
r VA100 General Arts & Crafts
r VA200 Ceramics
r VA201 Leather Craft
r VA202 Drawing & Painting
r VA204 Jewelry
r VA205 (Your Choice)
Wildlife
r WL100 Wildlife
r WL101 Sport Fishing
Woodworking
r WW100 All Phases
Exploring 4-H (7-9 year olds)
r EX100 All Phases
Entrepreneurship (12 and older)
r CIT100 Entrepreneurship
State Awards Program ( 14+) (Check with Extension Office)

For fair premium and junior livestock sale eligibility, 4-Her must attend 3 project meetings prior to the due date. To encourage the 4-H learn by doing philosophy, 4-Hers must attend 3 4-H project leader guided meetings (minimum of 30 minutes each) on 3 different dates throughout the 4-H year. Goal Setting Section 1 of Project Attendance form should be completed by Feb 1. New members should complete Section 1 within a month of enrollment.
__________________________________
Parent
__________________________________
Member
__________________________________
Date

To keep 4-H enrollment information secure and to improve of data management and reporting requirements, K-State Research and Extension will maintain 4-H enrollment information in an on-line database. This system will be managed on a certified secure server maintained by Cooperative Extension. Authorization: I understand all enrollment information may be stored in 4-H Online or a similar system. I further understand National 4-H Council will not use enrollment data to contact any youth, but may contact me as a parent/guardian. As the 4-H program is based on research, the contact will relate to 4-H outcomes research.
r Parent prefers not to be contacted by National 4-H Council related to 4-H research studies.
________ ___ ________________________________________________________ ___________________
4-H Member Signature Parent or Guardian Signature Date
Publications from Kansas State University are available on the Web at Contents of this publication may be freely reproduced for educational purposes. K-State Research and Extension is an equal opportunity provider and employer. Issued in furtherance of Cooperative Extension Work ,Acts of May 8 and June 30, 1914, as amended.