Carroll County
4-H Member Record Form
Name:
Age:
Number of Years in 4-H:
Club:
Age Group:
 Jr.(8-11)
 Int.(12-14)
 Sr. (15-up)
Annual Goals
Year:
Project
Name:
Goals
Date
Completed
Carroll County
4-H Member Record Form
Size and Growth of Projects
In the boxes below, express your size and growth within each project. Size should be express in quantities.
(Examples: Took 360 photos. Earned $300 babysitting. Spent 55 hours caring for pet.) Growth shows a progression
from the first year to the present year. (Example: Repaired 5 buttons. Put hidden zipper in dress. OR Made 15 art
items in 2000; Made 30 art items in 2001.)
Project
Name:
Year:
Year:
Year:
Year:
Carroll County
4-H Member Record Form
Knowledge and Skills
In the boxes below, list skills and knowledge you learned during the project year.
(Example: - Learned to use hand saw and hammer; select the correct type of nails used for a project; design a chest
and figure the lumber needed.) Do not need to know how many years or what year.
Year:
Project or
Curriculum
Area
Name:
I Learned:
Carroll County
4-H Member Record Form
Project Activity Participation, Leadership, & Community
Services-4-H Only
In the boxes below, list the activities you participated that are directly related to your project in during the project
year. (Example: - Foods- Skill-a-thon, Demonstration Contest; Gardening- plant workshop, horticulture judging.)
For talks & demos need to list what year; for activities list number of years participating.
Participation Level Abbreviations: L= Local, C=County, M=Multi-County, R=Regional, S=State, N=National
Project/
Projects
EXAMPLE:
Foods
Name:
Activities
Organized & Led Foods Workshop
Homemade Angel Food Cake -demo
Club Tour to Dairy Queen
Cooking with Beef Workshop
Collected Food for County Pantry
Levels
M
L
L
S
C
Years
Participated
07
07
08
07
08
Carroll County
4-H Member Record Form
Leadership – 4-H RelatedIn the boxes below, list the roles (club offices, county offices, club committees, 4-H ambassador, and county
committees) you served in. (Example: -club recreation chairperson, window display committee, Jr. Ambassador,
county fashion review committee.)
Year
Leadership Roles
Community Service – 4-H Related
In the boxes below, list the services provided.
(Example: Valentine Making with Nursing Home residence, plant flowers at fair grounds, assisted with County Fair)
Year
Community Service Activities
Other Accomplishments-4-H Related
In the boxes below, list other activities or awards not directly related to a project that you have participated in.
(Example: -4-H camp, Illini Academy, 4-H Softball, Top Junior Seamstress,)
Year
Name:
Activities
Carroll County
4-H Member Record Form
Participation-Non-4-H
In the boxes below, list the activities or awards not directly related to a project that you may have participated in.
(See example.) Also include non4-H Leadership & Community Service roles & activities.
Activity
Year
Example
2009-2010
Name:
Basketball, Volleyball, Softball
Boy Scouts
Spelling Bee (Local level, District level)
3-on-3 Basketball Tournament
Sunday School Program
Jr. Class Vice-President
Collected food for the food pantry
Carroll County
4-H Member Record Form
4-H Story
In the box below, write a story for each of your 4-H projects. Add more pages if needed. This should begin with the
beginning of the project area by telling why you started. Tell what success and failures you have had. Tell what
you have learned and what you might change the next time you do things. Tell how 4-H has changed you and your
family. Tell how 4-H has helped you think about what you want to be when you grow up.
Project Area(s):
Story:
Name:
Carroll County
4-H Member Record Form
Signature Portion
4-Her’s Signature:
Parent Comment:
Parent Signature:
Leader Comment:
Leader Signature:
Name: