Illinois 4-H Adult Enrollment Form
Logan County 2015-2016
This form is primarily for new adult participants in this group, but may be used by those re-enrolling if a preprinted
Illinois 4-H Individual Re-Enrollment Form is not available.
Group Name
 Adult Leader
 New
 Male  Female
 Re-enroll
Yrs in 4-H as volunteer
Date of Birth
/
(including this year)
/
First Name
MI
Last Name
Street Address
PO Box City
Zip Code
County of Residence
E-mail
Phone:
Type:
 Home Phone  Cell Phone
Phone:
Type:
 Home Phone  Cell Phone
T-Shirt Size
Youth
Adult
 Small  Medium  Large
 Small  Medium  Large  X-Large
 2XL  3XL
Residence
Race: (select one)
 Farm (where income is earned farming)
 Rural/Small Town (under 10,000)
 Medium Town (10,000-50,000)
 Suburb greater than 50,000
 City greater than 50,000
 American Indian or Alaskan Native  White
 Asian
 2 or more races
 Black or African American
 Some other race
 Native Hawaiian or Pacific Islander
Languages spoken at home
(please select all that apply)
Ethnicity




(If Hispanic, please select all that apply)
Arabic
Chinese
English
French




Polish
Spanish
Tagalog
Other
Hispanic or Latino





 Yes  No
Central American
Cuban
Dominican
Ecuadorian
Guatemalan





Mexican
Puerto Rican
South American
Spanish/Spaniard
Other
Mailing Lists
 Yes  No
 Yes  No
 Yes  No
I would like information on the county-level Foundation and how it supports the 4-H program.
I would like information on the Illinois 4-H Foundation and how it supports the 4-H program.
I would like information about events at the University of Illinois.
Continued on back (OVER)
__________________________________________________________________________________________________
Issued in furtherance of Cooperative Extension Work, Acts of May and June 30, 1914, in cooperation with the U.S. Department of Agriculture,
Dr. George Czapar, Associate Dean and Director, University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension
provides equal opportunities in programs and employment. The 4-H Name and Emblem are Protected Under 18 U.S.C. 707
Military Affiliation
 None
 Army
 Navy
 Air Force
 Army National Guard
 Navy Reserve
 Air National Guard
 Army Reserve
 Coast Guard
 Air Force Reserve
 Marine Corps
 Coast Guard Reserve
 Marine Corps Reserve
Photo/Video/Audio Release
 Yes  No
I grant to the University of Illinois Extension 4-H Youth Development Program, irrevocable
permission to record and/or disclose my identity, image, and voice arising out of documenting
4-H youth programs and to use, reproduce and distribute such in whole or in part in video and/or
sound recordings, films, photographs, transparencies, webpages, social media, local news
media or any other media for any purpose on behalf of the University and Extension without
compensation to me and without any right for me to inspect or approve the finished photograph,
video, or audio recording or other recordings.
Signature
Date
4-H Volunteer Behavior Guidelines:
Families and other youth-serving programs place trust in University of Illinois Extension to provide quality
leadership and care for participating youth. The opportunity to work with youth is a privileged position of trust that
should be held only by those who are willing to demonstrate behaviors that fulfill this trust. For these reasons, the
following behavior guidelines are expected of volunteers working in University of Illinois Extension 4-H youth
development programs.
1. Treat others in a courteous, respectful manner demonstrating behaviors appropriate to a positive
role model for youth.
2. Obey the laws of the locality, state, and nation and University of Illinois and Extension policies and
guidelines.
3. Make all reasonable effort to assure that 4-H youth development programs are accessible to youth
without regard to race, color, religion, gender, national origin, ancestry, marital status, familial status,
sexual orientation, or disability.
4. Recognize that verbal and/or physical abuse and/or neglect of youth is unacceptable in 4-H youth
development programs and report suspected abuse to the authorities.
5. Do not participate in or condone neglect or abuse, which happens outside the program to 4-H youth
participants, and report suspected abuse to authorities.
6. Treat animals humanely and teach 4-H youth to provide appropriate animal care.
7. Operate motor vehicles (including machines or equipment) in a safe and reliable manner when
working with 4-H youth. Adults must possess a valid operator’s license and the legally required
insurance coverage.
8. Do not consume alcohol or illegal substances while responsible for youth in 4-H activities nor allow
4-H youth participants under supervision to do so.
9. Use technology and social media in safe and appropriate ways. See “Illinois 4-H Social Media
Guidelines.”
I have read, understand, and agree to University of Illinois Extension Volunteer Behavior Guidelines. I am at least
18 years of age and have the full right and authority to execute this agreement. I agree to fulfill the responsibilities
of my volunteer position to the best of my ability if appointed. I understand that failure to comply with the rules
may lead to dismissal from this position.
Signature
Date ___________________
Revised 8/2015