Waushara County 4-H Older Youth Cultural Trip
Purpose of the trip:
 Learn about the cultural, historical, geographical/geological, political and economic aspects of one geographic region
in the Midwest.
 Have fun while interacting with other 4-H members and leaders.
 Experience different aspects of organizing and taking an overnight multi-day trip for a small group
Age:
Delegate must be in grades 9-13 at the time of enrollment.
Application Form: Complete and submit by established deadline to the UW-Extension Office.
Leader Recommendation: Ask your club’s organizational leader to complete the enclosed recommendation form and
return to the Extension Office by predetermined deadline. If your parent is your club’s organizational leader, please ask
another leader in your club to complete the recommendation form.
Interview: All applicants will be required to participate in an interview in January. Date posted in the newsletter and on
application.
Cost:
 Personal spending money for food and souvenirs.
 The Leader’s Association will provide a 66% scholarship toward the group expenses for travel, group meals, lodging
and admissions. Each participant will pay for one meal per day.
Responsibilities of Participants:
 participate in planning meetings
 report on assigned topics to share with the group in written and oral presentations
 follow through on assumed responsibilities by established deadlines
 show initiative when carrying out responsibilities during the trip
 be a team player when planning the trip and during the trip
 assist with any presentations (Fair, Member and Leader Recognition Day, others as requested)
 be a positive representative of Waushara County and of 4-H.
Health Form: Both parent/guardian and delegate sign.
Waushara County 4-H Older Youth Cultural Trip
Name
Male
Female _____
Grade ___________ Year in 4-H __________________
4-H Club _______________________________________________________________
Telephone (
)
E-mail address _________________________________
What do you hope to learn from participating in the Older Youth Cultural Trip?
What part(s) of the Midwest would you like to visit?
What behaviors do you think need to practice in order to be a good representative of 4-H and Waushara County while
participating in this program? Please list A MINIMUM OF FIVE BEHAVIORS.
1.)
4.)
2.)
5.)
3.)
6.)
If selected to be a delegate, how will you strengthen the team planning and participating in this trip? What attributes do
you possess that will make you a strong team member and benefit the group as a whole?
4-H Leadership: Please list the leadership positions you have held as a 4-H member. Leadership roles
include club officer positions, youth project leader, and committee chair positions. Attach additional
pages if necessary.
4-H Leadership Positions
Year(s)
What Did You Learn?
4-H ACTIVITIES: List activities you have participated in during your years as a 4-H member and what awards and
accomplishments you have received. Please check whether it was a club activity or county activity.
4-H ACTIVITIES
CLUB
COUNTY
YEAR(S)
WHAT HAVE YOU LEARNED?
Community service
Demonstration
Festival of the Arts
4-H Summer Camp
Recreation
Speech at club/speaking
contest
4-H Food Stand
Other 4-H Event (please
list):
COMMUNITY, CHURCH, SCHOOL ACTIVITIES OTHER THAN 4-H: List activities you have participated in
during school activities including clubs, teams, musical groups, etc.; community groups outside of school in which you
have participated for the betterment of your community such as church groups, clubs, Boy or Girl Scouts, volunteer
groups, or community art endeavors; and any leadership positions held.
COMMUNITY, CHURCH,
YEAR(S)
WHAT HAVE YOU LEARNED?
SCHOOL
LEADER'S RECOMMENDATION FOR OLDER YOUTH TRIP DELEGATES
Please return to: Waushara County Older Youth Trip Recommendation, P.O. Box 487, Wautoma, WI 54982 by April 1.
The information contained on this recommendation will be kept confidential.
Youth participating in Explore Wisconsin are to exhibit the qualities of being dependable, willing to show initiative, be
responsible for their own actions, get along with others in a positive manner, provide leadership as needed and express
information effectively both orally and in written form. If you need more space to comment, please write on the back of
the form.
Leader's recommendation for _________________________________________________________
Please rate the member in for each category in the chart: (1 is poor, 3 is neutral, 5 is wonderful)
1
2
3
4
5
Integrity (Member exhibits moral, ethical and legal behaviors)
Teamwork (Member puts team success before personal success)
Trust/Respect (Member sees and believes in the importance of others, and
makes others feel valued)
Caring/ Compassion (Member displays compassion, kindness, concern)
Ownership/Accountability (Member takes responsibility for own work,
actions, feelings and behaviors)
1. Why would this applicant be a good representative of Waushara County?
2. How does this applicant get along with other youth?
3. Does this member regularly exhibit behaviors that are NOT representative of 4-H?
Yes
No If yes, please explain:
I recommend this individual for participation in the Waushara County 4-H Explore Wisconsin program.
______Yes ______No
Please provide a brief explanation of your answer:
___________________________________
Leader's Signature
Explore Wisconsin and Older Youth Cultural Trip Commitment Form
Name _______________________________________________
This form must be returned to the UW-Extension Office, P.O. Box 487, Wautoma, WI 54982 by June 1 or earlier if
agreed upon by the group.
Realizing that it is a responsible part of being chosen for this trip, I _________________________
am signing this form as a commitment to participate in the trip. I will make payment of my share of the trip within one
month of receiving the bill for the trip. If I default on my commitment, I realize that I will be responsible for the entire
cost of the trip including the scholarship portion paid by the Waushara County 4-H Leaders Association which is 66% of
the cost of the trip. The Leaders Association’s Executive Board reserves the right to review the default and make a
decision to allow default.
Member Signature_________________________________________
Date ___________________
Parent/Guardian’s Signature _________________________________
Date ___________________