Berks 4-H Recognition Application
Name
Address
County
City
Male _____ Female _____
State
Zip
Years in 4-H_____
Telephone number _________________
Email Address:
Age as of January 1 of this year ___________________________ Date of Birth_____________________
Social SecurityNumber__________________________________________________________________
Name of Parent(s) or Guardian(s)
Name of 4-H Club 9s) or Program (s)
Name of 4-H Leader (s)
Are you currently enrolled in high school, college, or a vocational training program?
If so, what is the school’s name?
What year are you in?
What is your major area of study?
If you are not in school, what is your present job or career?
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I have personally prepared this application and believe it to be accurate.
Date
Member’s Signature
My signature below indicates that I have read this application and believe it to be correct. I certify that
this individual is a current and active member of the Berks 4-H Program, and I approve this application
for submission.
Date_________________________
Parents or Guardian’s Signature_
Date
Local 4-H leader’s Signature
Date
County Extension Educator’s Signature
The Pennsylvania State University is committed to the policy that all persons shall have equal access to programs, facilities,
admission, and employment without regard to personal characteristics not related to ability, performance, or qualifications
as determined by University policy or by state or federal authorities. It is the policy of the University to maintain an
academic and work environment free of discrimination, including harassment. The Pennsylvania State University prohibits
discrimination and harassment against any person because of age, ancestry, color, disability or handicap, genetic information,
national origin, race, religious creed, sex, sexual orientation, gender identity, or veteran status and retaliation due to the
reporting of discrimination or harassment. Discrimination, harassment, or retaliation against faculty, staff, or students will
not be tolerated at The Pennsylvania State University. Direct all inquiries regarding the nondiscrimination policy to the
Affirmative Action Director, The Pennsylvania State University, 328 Boucke Building, University Park, PA 16802-5901; Tel
814-863-04711150/TTY.
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PROJECT SUMMARY
List the 4-H projects that you have completed in each of the previous two 4-H years:
Year
Year
List the 4-H projects that you are enrolled in for the current year.
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1. Describe your two most important 4-H related communications experiences from the
current year or two previous 4-H years (e.g. presentation, public speaking, marketing
4-H, etc.). Limit your response to the space provided.
2. Describe your two most important 4-H related leadership experiences from the current or
two previous 4-H years (eg., club or county offices, county or regional committees, teen
council, camp counselor, etc.) Limit your response to the space provide
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3. Describe your two most important community service experiences from the current or
two previous years. Limit your response to the space provided.
4. Attach a one-page essay explaining how your 4-H experiences have helped you make a
difference in your club and county 4-H program, school or community. Also explain how
those experiences will help you contribute to a better society in the future. Use only one
side of one page, and type your response if possible. All typed responses should be
double-spaced.
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PROJECT & PARTICIPATION RESUME
Accomplishments & Experiences in 4-H.
Include the current year and the two previous years. Do not include your projects and
limit your information to the space provided.
*Goals Achieved
*Knowledge & Skills Acquired
*Club Actvities
*County Activities
*Regional, State, National Event
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