Full Name (First, Middle, Last) :
Birth Date: / / Primary Phone:
Work Phone:
Other Phone:

Mailing Address:
Email:
Mobile Phone:
City:

State: Zip:
  Email Newsletter
  Wants 4-H Mailings
  Member has health considerations:
Hispanic or Latino Ethnicity(check one):

Yes

No Gender:

Female

Male
Racial Groups: (check all that apply):

White

Black or African American

Native Hawaiian or Other Pacific Islander

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

Air Guard


Army Guard
Air Force Reserve


Army Reserve
Active Navy


Active Air Force
Naval Reserve

Active Marine Corps

Marine Corps Reserve

Active Coast Guard

Coast Guard Reserve
Please provide us with this optional data so that we may report to our Federal partners.
Parent/Guardian Name (Last, First, MI):
Parent/Guardian Work Phone: ( )
Time to Call: ___________ Parent/Guardian Email:
Parent/Guardian Name (Last, First, MI):
Siblings:
Grade in School:
Name of 4-H Club:
Parent Mobile Phone: ( )
 Primary Club 
Name of 4-H Club 2:
Name of 4-H Club 3:
Name of 4-H Club 4:

4-H Projects:
Project 1: Clover
Project 2:
Project 3:
Project 4:
Project 6:
Project 7:
Project 8:
Project 9:
Project 5: Project 10:
 Signed Maryland 4-H Behavioral Expectations attached.

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:
Parent/Guardian Signature:
Date:
Date:
4-H Volunteer/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 your child in the Maryland 4-H program. If you do not provide the requested information your child cannot be a 4-H member. 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