Multnomah County 4-H Club Leaders & Independent Leaders
Respond by September 15, 2015
Completely fill out the Annual 4-H Club / Independent Registration form.
This form:
 Tells us if we can refer new/additional 4-Hers to your club.
 Tells us know how many member and leader enrollment packets you need to get started.
 Identifies the Club Contact Leader – This is the adult leader who receives mailings and phone calls for
the club, and who is responsible for club financial reports.
 Allows us to accept member and leader enrollments for your club. We cannot accept member or
leader enrollments for your club until this form is turned in.
You must complete this request form to receive re-enrollment materials. As Club Contact Leader,
YOU are the only one in your club receiving this information. Please let us know if someone else will be
Club Contact Leader for the 2016 enrollment year.
ATTENTION – NEW ENROLLMENT DEADLINES!
January 10
 ALL Re-enrolling members who want to participate in 2016 County Fair
April 1
 NEW members to Multnomah County 4-H who want to participate in 2016 County Fair





Enrollment Information
4-H leaders and members must re-enroll each year. Enrollments do not continue automatically.
You are not enrolled in 4-H unless your completed enrollments and payments have been accepted by
the Extension office.
Participation fees must be included with member enrollments.
o Participation fees are $35 per member.
o Families with three or more members pay a maximum of $70.
o There are no participation fees for adult leaders.
Adults working with youth in the name of 4-H without being enrolled or without authorization of the
Extension office are not covered by the OSU / State of Oregon liability insurance afforded to 4-H
volunteers.
Club enrollments will not be accepted if the club’s Annual Financial Statement has not been received.
Please return this form so we can get you your re-enrollment materials quickly. If you have any questions,
contact Courtney Lobo at the Extension office, 971-361-9629. Thank you for being a 4-H volunteer!
Maureen Hosty
Extension Agent
4-H Youth Development
Annual 4-H Club / Independent Registration
Oregon State University Extension Service
3880 SE 8th Avenue, Suite 170, Portland, OR 97202
Club Name / Leader’s name if Independent: ____________________________________________
Does your club plan to enroll for the 2015-2016 year? (circle one):
YES
NO
Is your club open for new/additional members? (circle one):
YES
NO
Is your club open for new/additional Cloverbud members (ages 5-8)?
YES
NO
as of 9/1/15
Where does the club / independent group meet (city/area)?: ________________________________
Club projects (art, foods, cats, horse, etc. – please be specific): _____________________________
_______________________________________________________________________________
_______________________________________________________________________________
How many LEADER enrollment packets* do you need mailed to you?: ____________
How many MEMBER enrolment packets* do you need mailed to you?: ___________
* Leader and member enrollment packets are also available at http://extension.oregonstate.edu/portland/enrollment
2016 Club Contact Leader / Independent Adult Advisor – the adult leader who receives the
mailings and phone calls for the club / independent 4-H member(s).
Name: __________________________________________________________________________
Address: ________________________________________________________________________
City: ____________________________________________
State: _________
Zip: __________
Phone: ____________________________ E-mail: _____________________________________
Check this box to indicate that you agree to the non-discrimination statement:
 This club does not discriminate, restrict or deny any person membership or participation in its
programs or activities because of race, national origin, sex, ability or other protected status
(protected statuses include age, color, disability, gender identity or expression, genetic
information, marital status, national origin, race, religion, sex, sexual orientation, or veteran's
status).
FOR INDEPENDENT GROUPS ONLY:
I am the Adult Advisor for the following Independent 4-H member(s):
Member Names (first and last):
___________________________________________________________
___________________________________________________________
Office Use Only: Received: ___________
Entered On: __________
Entered By: ________