WICOMICO COUNTY 4-H
MEMBER FEE
PAYMENT FORM
A $10 4-H Member Fees apply to for each 4-H member who is aged 8-19 as of January of the 4-H
year. Clover aged members (5-7) do not pay a fee. Please complete this form and submit with
payment to the 4-H Office or your club leader. Questions or concerns please contact Amy Rhodes, 4-H
Educator – arhodes1@umd.edu, 410-749-6141. Forms can be mailed to Wicomico 4-H, Amy Rhodes,
Po Box 1836, Salisbury MD 21802.
Member(s) Information
1. Member Name_______________________________________________________________ ($10)
Club(s) _____________________________________________________________Club Fee$_______
2. Member Name ______________________________________________________________ ($10)
Club(s) _____________________________________________________________Club Fee$_______
3. Member Name _______________________________________________________________ ($10)
Club(s) _____________________________________________________________Club Fee$_______
4. Member Name __________________________________________________________ (no charge)
Club(s) _____________________________________________________________Club Fee$_______
PAYMENT – CHECKS PREFERRED, CHECKS MADE OUT TO WICOMICO EAC
$10 per child up to 3 children per family
Enrollment Fee $10 X ________(# children) = $_________
Club Fees$___________
Method - Cash_________ Check#____________ Total Amount Enclosed $___________
Notes______________________________________________________________________________
___________________________________________________________________________________
Guardian Print Name
Signature
“The University of Maryland is an Equal Opportunity Employer and Equal Access Programs”
For Office use Only: Date Submitted: __________ Date Approved: __________ 4-H Year_________
Date