Enrollment is not complete until Volunteer Code of Ethics and Conditions of Volunteer Service are signed, and background check is approved.
Legal Name (please print): _________________________________________________Preferred Name:__________________
Last First Middle
Mailing Address: ____________________________________________________________________________ __ _________
City: _______________________________________________________ State: ______________ Zip: __________ __________
Years in 4-H (counting this year) ______ Have you been involved in 4-H in Oregon before? Yes _____ No ______
Occupation (optional) _________________________ Highest Level of Education (optional) ____________________________
Has Health Considerations? Yes _____ No ______
Military Family? Yes ______ No _______ if so, what branch ____________________________________________________
Gender:  Male  Female Residence (Check one):  Farm  Rural/less than 10,000
 Town 10,000 to 50,000  Suburbs over 50,000  City over 50,000
Email: _________________________________________  Check to receive the monthly 4-H e-newsletter 
Primary Phone: __________________________ ___ Cell Phone: _________________ ________________________
 Okay to text this number? List Cell Phone Carrier ______________________________________________________
Please provide us with this optional data so that we may report to our federal partners.
Hispanic Ethnicity: (check one)
  Yes – Hispanic or Latino Ethnicity OR

No -- Not Hispanic or Latino Ethnicity
Racial Groups: (check all that apply)
 Asian  White  Black/African American  American Indian  Hawaiian or Pacific Islander  Prefer not to State
Are you a 4-H Resource Leader?

No

Yes (Not currently a 4-H Club leader at this time)
Does your club offer the Cloverbud Project?
  Yes
  No
Is your club accepting new members for the 2014-2015 4-H year?

Yes

No
Club Meeting Area (SE Portland, North Portland, Gresham, etc)_________________________________________________
Name of Primary 4-H Club: ______________________________________________________________________________
Club 2: _____________________________________________ __________________________________
Oregon State University Extension Service offers educational programs, activities, and materials without discrimination based on race, color, religion, sex, sexual orientation, national origin, age, marital status, disability, and disabled veteran or Vietnam-era veteran status. OSU Extension Service is an Equal Opportunity Employer. Reasonable accommodations will be provided to those with physical or mental disabilities in order to attend Extension programs. Please contact the Extension office in advance to make arrangements. Oregon State University is an Equal Opportunity Employer.
Revised 08/28/2014 page 1 of 6 (including 2 page Background/Criminal History Notice & Release)