LaSalle County 4-H Shooting Sports Enrollment Form
Name__________________________________________________ Male□
Parent’s Name______________________________________________
Female□
4-H member Birthday___/___/___ Grade _____
Mailing Address of Member____________________________________________City__________________Zip________
Home Phone(
)________-_____________ Alternate(
)_____-___________ County of Residence___________________
-----------------------------------------Behavior Guidelines-----------------------------------------I understand that if I am not currently enrolled in a 4-H Community Club, I will need to complete an additional 4-H
program enrollment form (attached) and pay a $20 fee in addition to the Shooting Sports program fee. All forms must be
processed thru my local Extension Office before starting a shooting sports program. I understand it is my responsibility
to do this.
I have reviewed the 4-H Behavior Guidelines and the Shooting Sports Rules. For list of guidelines and shooting sports
rules, see, http://web.extension.illinois.edu/blmp/4hss/3163.html .
------------------------------------Photo and Video Release--------------------------------
For the duration of this 4-H year, I grant the 4-H Youth Program, University of Illinois Extension, the permission to disclose
my (or my child’s) identity and to reproduce and distribute videotapes, films, photographs, and transparencies of me (or
my child) and sound recordings arising out of documenting 4-H youth programs.
□ Yes
□No
4-H member initials___________
Parent’s initials_____________
----------------------------------Discipline Annual Registrations and Fees------------------------------------____Archery—8 to 18 years old - $25 fee (new members and using provided equipment)
__I am a returning member - $20 fee
__I will bring my own equipment - $20 fee
____ Left eye dominate ____Right eye dominate
$______
$______
____.22 Riffle --10 to 18 years old- $25 fee (new members and using provided equipment)
__I am a returning member - $20 fee
__I will bring my own equipment - $20 fee
$______
$______
____Air Rifle —8 to 18 years old$25 fee (new members and using provided equipment)
__I am a returning member - $20 Fee
__I will bring my own equipment - $20 fee
$______
$______
____Shotgun-10 -18 years old- $50 fee (new members and using provided equipment)
__I will bring my own equipment -$45 fee
__I will bring my own equipment - $45 fee
$______
$______
Total Supply ……………………………………………………………………………………………………………………………………………………………………………………..$______
Make checks payable to: 4-H fee= University of Illinois Extension Shooting Sports Fee =4-H Shooting Sports forward to:
University of Illinois Extension, 1689 N. 31st Road, Suite 2, Ottawa, IL 61350.
We hereby accept all terms as mentioned above.
We/I give our/my permission for our child to participate in 4-H and agrees to support him/her with his/her elected
projects/activities.
Parent Signature______________________________________________________________________ Date________________
4-H Members Signature________________________________________________________________ Date________________