PA 4-H State Council Application
Please attach a head shot or close-up photo to this application.
Upon completion, return to Mya Rushton
8C Ferguson Building, University Park, Pa 16802
General Information
Full Name________________________________________________________ Preferred Name _________________
Address ______________________________________________ City _____________________ Zip ______________
Home Phone _______________ Cell Phone ________________ Email ____________________________________
Grade in School _________ Name of School _________________________County _______________________
Parents’ Names ___________________________________________________________________________________
Parent Contact Information________________________________________________________________________
Parents’ Employers ________________________________________________________________________________
4-H Information (attach additional pages if necessary)
Years in 4-H: _____________ Name of 4-H Club(s): ____________________________________________________
Major Project Areas: _______________________________________________________________________________
Projects taken: ____________________________________________________________________________________
Club offices held: _________________________________________________________________________________
County leadership experiences/events: ____________________________________________________________
___________________________________________________________________________________________________
Multi-county leadership experiences/events: _______________________________________________________
___________________________________________________________________________________________________
Regional leadership experiences/events: ___________________________________________________________
___________________________________________________________________________________________________
State leadership experiences/events: ______________________________________________________________
___________________________________________________________________________________________________
National leadership experiences/events: ___________________________________________________________
Other Information
Why do you want to be on State 4-H Council? ______________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Why do you think you would be a good State Council member? ____________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Explain what you would do to successfully fulfill the responsibilities and duties of a State Council
member. _________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
List and describe your public speaking experiences. ________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
If selected to State Council, would you be interested in holding an office? ___________________________
If yes, for which position or position(s) would you be interested in running? ____________________________
Essay Portion
Please answer the following questions briefly and concisely. Please use the back of the page if
needed or attach your responses.
1. Who is your role model and why?
2. Describe your most rewarding 4-H experience.
3. What would you like to accomplish while on State Council?
4. What do you think is the single most important item to remember while representing Pennsylvania
while on the Pennsylvania State 4-H Council?
5. Describe the other time commitments you will have for the upcoming year (examples: sports,
religious activities, clubs, community groups, etc.)
6. If selected, how will you balance your other time commitments with being on State Council?
7. How has 4-H enhanced your life?
8. What do you believe are the key characteristics of a good leader?
9. How have you demonstrated these characteristics in your own life?
10. How do you handle conflicts or disagreements?
11. What strengths, talents, and/or ideas will you bring to the State Council?
References
Secure three references (one must be from a county extension staff member, one from a 4-H leader
and one from a teacher or administrator of your school. Provide the attached form to each individual.
Ask references to be returned directly to the State 4-H office (address at top of application)
If references are not received, your application is not complete and you will not be considered for a
spot on State Council. Individuals you have asked to complete reference forms are:
Reference Name
Relationship to Applicant
Phone Number
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
I have personally prepared this report and believe it to be correct.
Signature of applicant____________________________________________________
Date _________________
Pennsylvania State 4-H Council Member Reference Form
Return to:
Mya R. Rushton, 8C Ferguson Building, University Park, PA 16802
If selected, this applicant may be planning county, regional and state events, leading discussion
groups, teaching workshops, working with youth, peers, and adults, and promoting 4-H at large, at
local and state events.
Applicant’s Name _________________________________________________________________________________
In what way have you been affiliated with this applicant? ___________________________________________
How long have you been acquainted with the applicant? __________________________________________
Personal Skills
Is confident
Adjusts to new situations
Has variety of interests
Is creative
Is enthusiastic
Knows personal assets
Knows personal values
Comments:
Poor
1
1
1
1
1
1
1
Interpersonal Skills
Cooperative
Tolerant of differences
Sensitive to others
Manages personal conflict
Manages conflict with others
Is diplomatic
Comments:
1
1
1
1
1
1
2
2
2
2
2
2
1
1
1
1
1
3
3
3
3
3
3
Average
2
2
2
2
2
Poor
1
1
1
1
1
1
1
3
3
3
3
3
3
3
Average
Poor
Organizational Skills
Identifies details
Can see “big” perspective
Can set priorities
Follows through
Can work under pressure
Can plan a meeting
Can lead a meeting
Comments
2
2
2
2
2
2
2
Poor
Communication Skills
Listens well
Expresses him/herself well
One to one communication
Small group communication
Public speaking
Comments:
Average
3
3
3
3
3
Average
2
2
2
2
2
2
2
3
3
3
3
3
3
3
Outstanding
4
4
4
4
4
4
4
5
5
5
5
5
5
5
Outstanding
4
4
4
4
4
4
Not
Observed
5
5
5
5
5
Outstanding
4
4
4
4
4
4
4
Not
Observed
5
5
5
5
5
5
Outstanding
4
4
4
4
4
Not
Observed
5
5
5
5
5
5
5
Not
Observed
Teaching Skills
Can facilitate discussion
Can give directions
Is organized
Involves learners
Comments:
Poor
1
1
1
1
Leadership Skills
Respected by peers
Respected by adults
Can guide peers
Can solve problems
Encourages teamwork
Can delegate to others
Asks questions, evaluates
Invites change
Comments:
Average
2
2
2
2
Poor
1
1
1
1
1
1
1
1
3
3
3
3
Average
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Outstanding
4
4
4
4
Not
Observed
5
5
5
5
Outstanding
4
4
4
4
4
4
4
4
Not
Observed
5
5
5
5
5
5
5
5
Based on your knowledge of, and experience with this applicant, do you think he/she would be an
asset to the Pennsylvania State 4-H Council organization? Why?
Do you recommend the applicant be a Pennsylvania State 4-H Council member?
Yes
No
Signature _________________________________________________
Date ______________
Title ______________________________________________________
Phone number ___________________
Acknowledgement Form & Pledge of Office
By signing this form, you acknowledge that you have received and read all Pennsylvania State 4-H Council informational
sheets and handbook and understand the materials contained therein and are in agreement and accordance with all rights,
responsibilities and policies of the PS4-HC. Please have all necessary individuals read and sign the pledge. Once all signatures
have been received, the original should be returned to the State Council office, and copies should be retained by the Council
member, the Council member’s parent or guardian and the Council member’s Extension Educator.
--------------------------------------------------------------------------------------I ______________________, agree to perform the duties and uphold the position for which I have been selected and agree to
the following:
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Serve as a liaison for all youth involved in the 4-H program and county and state staff
Be available for workshops and programs at the local, county, multi-county, regional or state level
Seek opportunities to expand the diversity of the 4-H program
Live up to the high expectations and values of the Pennsylvania 4-H program
Take the initiative to do more than what is expected of you; success requires more than the minimum
effort
Attend State 4-H Achievement Days 2011 for interview, presentation and speech.
Appearance encouraged at Ag Progress Days August 16-18, 2011
Attend the training and orientation weekend, August or September, 2011
Attend National Youth Science Day event October 2011
Attend the second training weekend held at Penn State University in January 2012
Attend the State 4-H Leadership Conference, January 20-22, 2012
Attend Farm Show Governor’s Dinner and Opening Ceremony
Attend Pennsylvania 4-H Capital Days (including one advance preparation day)
Attend, State 4-H Achievement Days 2012 as a State 4-H Council member NOT in competition
Attend a minimum of 8 of the 10 Council meetings (held either in person or via conference call)
Complete a minimum of 10 of 12 monthly reports
** Late reports are considered MISSED reports**
Attend two (2) 4-H events where you wear your PS4-HC formal or informal uniforms for a scheduled
event
Could include: state horse show, state dairy show, regional teen retreats, camps, and national events
Complete two (2) promotional activities for the state-wide 4-H program.
Could include: Farm City Day, PSATS Reception, and others as scheduled
Submit and maintain Council blogs, ATS articles, facebook and Twitter
Attend county, multi-county, regional and other events as needed or requested
Purchase appropriate official and unofficial attire when required
I agree to accept my responsibilities as a State 4-H Council Member and will abide by the Pledge of Office as previously
stated. I understand that if I do not fulfill my obligations or conduct myself in a manner inappropriate to the position, I will
face the consequences of my actions and could be removed from office. Realizing that the Pledge of Office as outlined is not
“all inclusive,” I understand that the Council Advisor Team reserves the right to interpret policies in the best interest of the
Pennsylvania 4-H program.
Council Members’ Signature_____________________________________________________ Date ___________________
I have read the 4-H Council Handbook and understand the responsibilities my child has accepted. I will support the
Pennsylvania 4-H program and my child in fulfilling these duties and responsibilities.
Parent/Guardian’s Signature ___________________________________________________ Date____________________
I have read the 4-H Council Handbook and understand the responsibilities this member has accepted. I will support the
Pennsylvania 4-H program and this member in fulfilling these duties and responsibilities.
Ext Educator’s Signature ___________________________________________________ Date____________________
State Council Uniform and Accessories Orders
If selected to serve: Council members need to send $50 to cover attire expenses
All checks need to be made payable to Penn State
Please return this form, and a wallet sized photo
WITH APPLICATION PACKET, to:
Mya R. Rushton 8C Ferguson Building
University Park, PA 16802
Council Blazers &Skirts/Trousers
Please fill in the appropriate measurements below. You will need to fill in both measurements AND the
approximate size. This allows the clothing company to custom fit the attire.
Men- Blazers
Women- Blazers
Chest
Waist
Hip
Arm Length
Chest
Waist
Hip
Arm Length
Men- Trousers
Waist
Inseam
Women- Skirts
Waist
Inseam
Council Polo Shirts
Please check in the space below what size polo you need
______ S
______ M
______ L
______ XL
Council Name Tags
Please fill out EXACTLY the way you would like it on your name tag
Name____________________________________________________
Council Business Cards
Please fill out EXACTLY the way you would like it on your business cards
Name___________________________________________
Address _________________________________________
City ________________ State PA
Zip _________
Phone _______________
Cell Phone _______________
Email Address _____________________ AOL IM Name _____________________
______ XXL