MARYLAND 4-H VOLUNTEER ENROLLMENT
Full Name (First, Middle, Last):
Primary Phone:
Work Phone:
Mobile Phone:
Other Phone:
Email:

Mailing Address:
City:
State:

Email Newsletter
Zip:
Wants 4-H Mailings
 Volunteer has health considerations:
Hispanic or Latino Ethnicity(check one):  Yes  No
Racial Groups: (check all that apply):
 White
 Black or African American
 Native Hawaiian or Other Pacific Islander
Gender:  Female
 Male
 American Indian or Alaskan Native
 Asian
Residence (Check one):  Farm  Rural/Town less than 10,000  Town/City 10,000 to 50,000
 Suburb over 50,000  City over 50,000
Military Family: (Check applicable box)
Active Army
Army Guard
Army Reserve
Air Guard
Air Force Reserve
Active Navy
Active Marine Corps Marine Corps Reserve Active Coast Guard
Active Air Force
Naval Reserve
Coast Guard Reserve
Please provide us with this optional data so that we may report to our Federal partners.
Name of 4-H Club:
Primary Club
Name of 4-H Club 2:
Name of 4-H Club 3:
Name of 4-H Club 4:
Continue on back 
4-H Projects:
Project 1:
Project 6:
Project 2:
Project 7:
Project 3:
Project 8:
Project 4:
Project 9:
Project 5:
Project 10:
 I give permission to the College of Agriculture and Natural Resources, University of Maryland, to use and
publish my photograph for education and promotional purposes without compensation.
Participant Signature:
Date:
4-H Club Leader Signature:
Date:
University of Maryland Extension programs are open to all citizens and will not discriminate against anyone
because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national origin,
marital status, genetic information, or political affiliation, or gender identity and expression.
UME is collecting information in order to enroll you as a volunteer in the Maryland 4-H program. The information you provide will be
shared with county and state fair associations. Information provided to the University may also be shared among offices within the
University and with the University System of Maryland and outside entities as necessary or appropriate in the conduct of legitimate
University business and consistent with applicable law. Because the University is a State educational institution, such information may
also be subject to disclosure under the Maryland Access to Public Records Act. Individuals may inspect and/or correct their personal
information as provided by the Public Records Act and/or other applicable law or University policy.
11/13/2012