Attach a photo of
yourself here or send a
digital photo to
dstocker@illinois.edu.
4-H Great Debate
2015 Planning Committee Application
(Due by November 1, 2014)
Please type or print – in ink.
Please check one:
____ Youth Applicant
_____ Adult Applicant
Name:
Address:
City/State/Zip:
Home Phone:
(
Birthdate:
)
Cell
Phone:
/
/
(
)
Age as of
9/1/2014:
County:
Year in school as of 9/1/2014: 10 11 12 College
Email:
College Address (if
applicable):
City/State/Zip:
College Email:
No. of Years Attended 4-H Great Debate:
Never
1
2
3
4 or more
Please list CURRENT Leadership Positions that you hold and the organization (i.e. 4-H, Religious, School club, Other
community group, etc.). Please also indicate if they are local, county, or state leadership positions.) (Adults, please
note any positions that involve you working with young people.)
Please list PAST Leadership Positions that you have held and the organization (i.e. 4-H, Religious, School club, Other
community group, etc.). Please also indicate if they are local, county, or state leadership positions.) (Adults, please
note any positions that involved you working with young people.)
(continued)
Which words come closest to describing your personality style/interests (Select a maximum of three):
Enjoy science, methodical, check out all the alternatives before making decisions
Fun-loving, risk-taker, enjoy coming up with new ideas
Love technology, always on computer, games (does not include social networking!)
Outdoors whenever possible, love to camp, be with nature
Organized, live by the calendar
Relationship-oriented, enjoy being with friends
Competitive sports
Music, Dance, the Arts
Why are you interested in serving on this planning committee?
What do you feel is your greatest strength?
What skills and/or abilities do you have to offer this committee?
What aspects of the 4-H Great Debate are most important to you? (i.e. socialization, debating a bill, learning about our
state legislature, etc.)
Youth Applicants - One Reference Evaluation (attached form) must be attached to this application. That reference
evaluation must be from a University of Illinois Extension staff member or 4-H volunteer leader. Note that the forms
must be placed in sealed envelopes by the evaluators.
Adult Applicants – These two items must be attached to this application:
 Two Reference Evaluations (attached form) must be attached to this application. One of those reference
evaluations must be from someone who has witnessed your work with young audiences. Note that the forms
must be placed in sealed envelopes by the evaluators.
 Completed University of Illinois Extension Volunteer Application, CANTS Check Authorization Form, and
Conviction Information Name Check Request Form. If you have already completed these forms for a local
Extension office, photocopies of the forms are acceptable (providing that the form has been completed within
the past 4 years.)
If selected, I realize that I am required to attend a minimum of 3 planning committee teleconferences (4-5 will be
held) during the coming year AND the 2014 event (dates still to be determined). Committee members are required to
arrive late afternoon before the 4-H Great Debate starts to assist with set-up. I also realize that should I fail to meet
these requirements that I will be dismissed from the committee.
Applicant Signature:
Parent/Guardian Signature:*
Extension Staff or School Instructor Signature:*
Must be postmarked no later than November 1, 2014. Send to: Deb Stocker, State 4-H Office; 801 N. Country
Fair, Drive, Suite E, Champaign, IL 61821. FAX, 217/333-9287. E-mail: dstocker@illinois.edu.
4-H Great Debate Planning Committee
Reference Evaluation
Name of Applicant
Name of Evaluator
Address
City, State, Zip
Circle one:
Extension Staff
4-H Volunteer
High School/College Instructor
Other:
Evaluator, please rate the applicant on the following (U - unknown and 1-poor to 5-excellent). For a Youth applicant,
please complete only the first two sections; for an Adult applicant, please complete the entire form. Each evaluator should
place the completed form in a sealed envelope with the applicant’s name on the front and the evaluator’s signature
across the seal. Envelopes should be returned to the applicant for attachment to the application.
Unknown Poor
Excellent
Ability to work w/ different and diverse audiences (i.e. adults,
ethnic groups, etc.)
U
1
2
3
4
5
Willingness to work with others, regardless of diversity within a group.
U
1
2
3
4
5
Does fair share of work on joint projects
U
1
2
3
4
5
Serves as an appropriate role model
U
1
2
3
4
5
Communicates ideas effectively.
U
1
2
3
4
5
Ability to get others to work together; compromise.
U
1
2
3
4
5
Carries through with responsibilities; knows when to say “no”.
U
1
2
3
4
5
Attitude (i.e. positive, professional, not arrogant.)
U
1
2
3
4
5
Appearance (neat, well-groomed)
U
1
2
3
4
5
Accepts and completes work assignments.
U
1
2
3
4
5
Exhibits enthusiasm in regard to performing needed tasks.
U
1
2
3
4
5
Exhibits appropriate behavior in public venues.
U
1
2
3
4
5
For Adult applicants only:
Ability to work alongside teens in a partnership
U
1
2
3
4
5
Provides guidance to youth in a professional manner
U
1
2
3
4
5
Enjoys working with teens and has extensive experience doing so
U
1
2
3
4
5
(does not “take over” discussions or tasks)
Please add any additional comments regarding this applicant on the reverse side.
Signature of Evaluator:
Date: