Cooperative Extension  University of Wisconsin-Extension
Revised 2-1-2001
Walworth County 4-H
PERMANENT PARTICIPATION RECORD
NAME
PARENT/GUARDIAN NAME
ADDRESS (Street or RFD, City, State, Zip Code)
DATE OF BIRTH
CLUB
PURPOSE OF 4-H WORK
To help young people in the development of: Character, Leadership, Attitudes and Ideals.
MEMBER PARTICIPATION RECOGNITION SYSTEM
•
•
•
•
Helps you carry out the purpose of 4-H in your own life,
Helps you see the many different things you can do in the 4-H Program,
Gives you a method for summarizing your own 4-H achievements, and
Encourages you to keep accurate and complete records.
PURPOSE OF PERMANENT RECORD
The purpose of the Permanent Record is to measure a 4-H member's involvement in club and community
activities and as an evaluation to earn Bronze, Silver, and Gold participation pins.
The Permanent Record is a 4-H member's "4-H Life History" and in the future will serve as a resource for
4-H trips, awards and scholarships, as well as school and job applications.
FOR CLUB LEADER USE ONLY
ACHIEVEMENT PINS EARNED
BRONZE
SILVER
GOLD
DATE
DATE
DATE
LEADER SIGNATURE
LEADER SIGNATURE
LEADER SIGNATURE
Page 2
LOCAL 4-H MEETINGS
YEAR
Number of club meetings held this year
Number of meetings I attended this year
Count 1 point for each meeting attended, up to 12 per year.
Enter total on Line 1 of 4-H Participation Report.
4-H PROJECT SUMMARY
In order to consider a project completed, you must have exhibited that project at your 4-H club or the
County Fair.
WHERE EXHIBITED:
YEAR
LIST PROJECTS ENROLLED IN
CHECK
IF
COMPLETED

C=CLUB
W=WAL. CO. FAIR
S=ST. FAIR
O=OTHER
N=NOT EXH.
Continued on Page 3
Page 3
4-H PROJECT SUMMARY (cont.)
WHERE EXHIBITED:
YEAR
LIST PROJECTS ENROLLED IN
CHECK
IF
COMPLETED

C=CLUB
W=WAL. CO. FAIR
S=ST. FAIR
O=OTHER
N=NOT EXH.
Continued on Page 4
Page 4
4-H PROJECT SUMMARY (cont.)
WHERE EXHIBITED:
YEAR
LIST PROJECTS ENROLLED IN
CHECK
IF
COMPLETED

Add additional pages if needed.
PROJECTS COMPLETED/EXHIBITED
Count number of projects rather than the number of items completed.
YEAR
Number of projects completed / exhibited this
year
Count 1 point for each project completed/ exhibited.
Enter total on Line 2 of 4-H Participation Report.
C=CLUB
W=WAL. CO. FAIR
S=ST. FAIR
O=OTHER
N=NOT EXH.
Page 5
4-H COMMUNICATION ACTIVITIES
Examples:
4-H public speaking, 4-H demonstrations, 4-H promotional talks, 4-H news stories, radio
or TV appearances. Use only one line to report each year’s activities.
PROJECT OR
ACTIVITY
YEAR
SUBJECT OR
TITLE
NMBR. OF
TIMES
GIVEN
WHERE
PRESENTED/
GROUP SIZE
YEAR
TOTAL THIS YEAR
Count 1 point for each demo, talk, radio or TV appearance, and news story.
Enter total (up to a maximum of 3 points) on Line 3 of 4-H Participation Report.
Page 6
COMMUNITY SERVICE, CONSERVATION, OR BEAUTIFICATION
Report only when you participate with other members of your club
in a group-planned activity to educate or benefit your community.
DESCRIBE ACTIVITY AND
HOW YOU WERE INVOLVED.
YEAR
TOTAL THIS YEAR
Count 1 point for each activity per year. Enter total on Line 4 of 4-H Participation Report.
CLUB HEALTH & SAFETY EDUCATIONAL PROGRAMS
Report only when you present or participate in a planned activity in your club.
DESCRIBE ACTIVITY AND
HOW YOU WERE INVOLVED.
YEAR
TOTAL THIS YEAR
Count 1 point for each program per year. Enter total on Line 5 of 4-H Participation Report.
Page 7
4-H MUSIC & DRAMA ACTIVITIES
Report only when you participate in a 4-H group-planned activity. Count only plays and musicals
presented at Music and Drama Festivals, Walworth County Reach Out, or club-organized events.
DESCRIBE ACTIVITY AND HOW
YOU WERE INVOLVED.
YEAR
TOTAL THIS YEAR
Count 1 point per activity up to a maximum of 3 points per year.
Enter total on Line 6 of 4-H Participation Report.
Page 8
4-H OFFICES & COMMITTEE ASSIGNMENTS
4-H OFFICES
A. List the offices you have held at local, county and state levels.
B. Use letter codes to describe level of office: L=Local, C=County, S=State.
Name of Office
YEAR
TOTAL THIS YEAR
Count 2 points per office held. Enter total on Line 7 of 4-H Participation Report.
COMMITTEES
A. List your committee assignments for local club, county and state.
B. Write in "C" for Chair or "M" for Member of each committee.
Name of Committee
YEAR
Continued on Page 9
Page 9
4-H OFFICES & COMMITTEE ASSIGNMENTS (cont.)
Name of Committee
Committee Membership
YEAR
YEAR
TOTAL THIS YEAR
Count 1 point for each "M" - committee membership (Maximum: 3 points per year.)
Enter total on Line 8 of 4-H Participation Report.
Committee Chairship
YEAR
TOTAL THIS YEAR
Count 2 points for each "C" (committee chairship).
Enter total on Line 9 of 4-H Participation Report.
Page 10
YOUTH LEADERSHIP – LOCAL CLUB
Responsibilities for 4-H group, encouraging leadership development in younger members,
helping members develop skills, planning a series of meetings, etc.
YEAR
PROJECT OR
ACTIVITY
NMBR. OF
YOUTH YOU
ASSISTED
LIST YOUR SPECIFIC LEADERSHIP RESPONSIBILITY
YEAR
TOTAL PROJECTS OR ACTIVITIES THIS YEAR
Count 1 point for each youth leadership project or activity.
Enter total on Line 10 of 4-H Participation Report.
YOUTH LEADERSHIP - MULTI-CLUB, COUNTY,
MULTI-COUNTY, OR STATE 4-H PROGRAM
Example:
County junior project leader, camp counselor, animal species committee member, explorer
counselor, State Leaders' Council, etc.
YEAR
LIST SIGNIFICANT 4-H LEADERSHIP EXPERIENCES BEYOND CLUB LEVEL
YEAR
TOTAL THIS YEAR
Count 1 point per leadership contribution. Enter total on Line 11 of 4-H Participation Report.
Page 11
OTHER COUNTY, STATE & NATIONAL EVENTS
County / Area Events
YEAR
Recreation (Softball, Bowling)
Spring Fling
County Explorers Camp
County Summer Camp
Exchange Trips (In-State or Out-of-State)
Officer Training
Kids' College
Walworth County Fair
Communication Arts Festival
Record Book Recognition
Area Animal Science Day
Favorite Foods Revue
Pizza Sale
Reach Out
County Shoot-Off
List Others:
TOTAL COUNTY/AREA EVENTS THIS YEAR
You must participate in at least 3 county-level events to be able to count any points.
Count 1 point per event if you took part in at least 3 or more county/area events.
Enter total on Line 12 of 4-H Participation Report.
State/National Events
YEAR
State 4-H Conference
Citizenship Washington Focus
National 4-H Congress
National 4-H Conference
Wisconsin State Fair
State Art or Photo Team
Showcase Singers or State Drama Team
List Others:
TOTAL ST./NATL. EVENTS THIS YEAR
Count 1 point for each state or national event. Enter total on Line 13 of 4-H Participation Report.
Page 12
OTHER 4-H PARTICIPATION
Include all 4-H participation not reported elsewhere. Examples: Master of Ceremonies, song leader,
Bankers' Night Awards, fundraiser, special club activities (examples: roller skating, summer fun, winter
fun, etc.).
YEAR
EVENT
CONTRIBUTIONS
Continued on Page 13
Page 13
OTHER 4-H PARTICIPATION (cont.)
YEAR
EVENT
CONTRIBUTIONS
Add additional pages if needed.
YEAR
TOTAL THIS YEAR
Count 1 point per event or activity up to a maximum of 5 points per year.
Enter total on Line 14 of 4-H Participation Report.
Page 14
NON-4-H PARTICIPATION
Report participation, special leadership roles and recognition (Examples: church choir, Scouts, FFA,
sports, school newspaper, etc.).
YEAR
ORGANIZATION/ACTIVITY
INVOLVEMENT OR RECOGNITION
Continued on Page 15
Page 15
NON-4-H PARTICIPATION (cont.)
YEAR
ACTIVITY
INVOLVEMENT OR RECOGNITION
YEAR
TOTAL THIS YEAR
Count maximum of 1 point per year for non 4-H participation.
Enter 0 or 1 on Line 15 of 4-H Participation Report.
Page 16
4-H PARTICIPATION REPORT
Instructions:
Refer to the Walworth County 4-H Permanent Record for an explanation of categories below.
List your accomplishments on your Permanent Record before entering totals on this
report. No activity is to be reported more than one time.
YEARLY ACHIEVEMENTS
(Enter yearly point totals from your Permanent Record)
YEAR
1.
Nmbr. of club/unit meetings attended. (Page
2) (Maximum: 12 points/year)
2.
Projects completed and exhibited.
(Page 4)
3.
Demo, talk, radio, TV or news story.
(Page 5) (Maximum: 3 points/year)
4.
Participation in community service,
conservation, or beautification. (Page 6)
5.
Participation in club health & safety
educational programs. (Page 6)
6.
Participation in 4-H music/drama activity.
(Page 7) (Maximum: 3 points/year)
7.
4-H offices held. (Page 8)
8.
Membership on committees. (Page 9)
(Maximum: 3 points/year)
9.
Chairperson of committees. (Page 9)
10.
Youth Leadership at local level.
(Page 10 - Required for Gold Pin.)
11.
4-H leadership responsibilities beyond club
level. (Page 10)
12.
Participation in other county/area events.
(Page 11)
13.
Participation in state or national events. (Page
11)
14.
Other 4-H participation. (Page 13)
(Maximum: 5 points/year)
15.
Participation in non 4-H activities.
(Page 15) (Maximum: 1 point/year)
YEARLY POINT TOTAL(S)
TOTAL POINTS (All years combined)
Pin applied for:
Bronze
75 points required to earn
Silver
125 points required to earn
Gold
200 points required to earn
S:\UW Extension\4H\FORMS\Project lit 4 RB\Current Forms\PPR.doc