SENIOR BLUE FORM
SULLIVAN COUNTY 4-H MEMBER'S RECORD
(This is an "easy to keep" record form for 4-H projects and members' activities. It may be used by
members 14 years old by January through age 18 for keeping the records for future reference. It is a
requirement for attending the 4-H Achievement Trip, and any regional and state events after the due
date.
20___
NAME ________________________________________________________
ADDRESS _____________________________________________________
Age last January 1 ___________
Date of Birth ________________________
Month
Day
Year
This is my ________Year in 4-H.
number
The name(s) of my current 4-H leader are_____________________________ __________________
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Member's Signature __________________________________________
Date _____________
Parent or guardian's remarks or statement: How have 4-H experiences helped your son or daughter?
Does this 4-H club member have your permission to participate in trips and other activities sponsored by
4-H clubs?
Yes _________ No _________
Parent's Signature _________________________________________________
Club Leader's Remarks or Statement: How has 4-H helped this member to develop personally?
Leader's Signature __________________________________________________
1
4-H PROJECTS COMPLETED:
Write the years in the number 1 column that you were in 4-H. In column 2, list the project or projects
you carried. In column 3, put the size or unit of the project. In column 4, indicate if you completed this
project by exhibiting at Roundup or otherwise completing. In column 5, list the award you received for
this project. Put your first year on the first line. Be sure and list your projects for this year in column 1,
2, and 3.
EXAMPLE
1
2
3
4
5
1993
Entomology
Unit 1
Completed at Roundup
Blue Ribbon
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1994
Foods For Some Special Unit 1
Completed at Roundup
Red Ribbon
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1995
Entomology
Unit 11
Completed at Roundup
Blue Ribbon
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1995
Hiking
Unit 1
Completed at Roundup
Blue Ribbon
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2
4-H Projects (Continued)
1
2
3
4
5
1993
Entomology
Unit 1
Completed at Roundup
Blue Ribbon
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3
4-H ACTIVITIES
1. Have you prepared and given talks to 4-H groups?
List Here: Include those to your club on: activities, school talks, talks at regional or state events.
Title of Talk
Date Given
Group you spoke to
______________________________________________________________________________
______________________________________________________________________________
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2. Have you written news articles about 4-H?
List Here: News Reporter articles or other 4-H articles for paper.
Topic of Article
Where Article appeared
Date
_______________________________________________________________________
_______________________________________________________________________
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3. Did you help with a Club Exhibit at Roundup?
Exhibit (title)
Date
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Did you help with a 4-H Float for a parade? (At Dairy Festival, or other parade)
Theme of Float
Date
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4
4-H Activities - Contd..
5. Did you participate in any Community Service Projects? (Community Cleanups; Heart; Cancer
Drive; Blood Mobile; Helping the Elderly, Visiting Nursing Home, Etc.)
What Projects?
Date
Was it a Club Activity?
_______________________________________________________________________________
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6. Did you do a 4-H Demonstration (s)?
Title
Date
To whom presented
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7. Did you do any 4-H Judging? (Exhibit at Roundup, the fair, your club, etc.)
Did you judge as an individual or a team?
What did you judge?
Date
_____________________________________________________________________________
_____________________________________________________________________________
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5
ACTIVITIES IN CHURCH, SCHOOL, AND COMMUNITY
OTHER THAN 4-H
List participation and offices in other organizations, school, and church. State which year you
participated..
CHURCH: (Sunday School, Choir, Candle Lighting, Collection, Church Picnics, Fund Raisers, Trips,
Church Camp, etc.)
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SCHOOL: (Sports, Yearbook, Honor Society, Band or Chorus, Honors won, events participated in,
Class officer, Class trips, fairs, Fund-raisers, Dramatics, Tutors, Office Helper, Plays, Music Programs,
Proms, etc.)
____________________________________________________________
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COMMUNITY: (Sports, EMT, Fire Company, Scouts, Library or other volunteer, Scouts, etc.)
____________________________________________________________
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6
4-H CLUB ACTIVITIES
Clubs (list first year first)
Club name
Year
Number of
members
Number of
meetings held
Number of
meeting attended
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Additional 4-H Club Activities: (trips, tours, picnics)
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Club offices- List the year and the club offices you have held.( list first year, first)
Example:
1992 - Game Leader
1993 - Secretary, Song Leader
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4-H County Activities: List the years and how you participated in these activities.
4-H Camp Brule_____________________________________________
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One-Day Camp________________________________________________
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Achievement Trip______________________________________________
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Officer Training Meetings_________________________________________
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Roundup/Achievement Night ________________________________________
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Other 4-H Activities _____________________________________________
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8
What new ideas or suggestions do you have for making your 4-H club (s) better next year? (Be
positive!)
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List at least one personal goal for next year.
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List something you experienced for the first time in 4-H or because of 4-H that you might not
have gotten to do otherwise.
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9
YOUR 4-H STORY: Write a story about how your 4-H experiences influence your future personal
growth with regard to the following areas- responsibilities, service to others, citizenship, personal values,
and career decisions.
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YOUR 4-H STORY CONTINUED
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YOUR 4-H STORY CONTINUED
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