ILLINOIS 4-H GROUP ENROLLMENT SHORT FORM
(Form #90104)
TODAY’S DATE ______/______/______
INSTRUCTIONS
(For Office Use Only)
This form is used to report all members and leaders who
are participating in University of Illinois Extension youth
groups and programs. The group’s leader should
complete this form with the exception of the “For Office
Use Only” box which the County Extension Office should
complete. The Project Names under “ALL YOUTH, Youth
Project/Activity Participation” may also need to be
completed by the County Extension Office.
All Extension youth programs, including one-time events,
should be reported using this form, especially when these
programs involve youth who are not otherwise enrolled in
4-H this year.
Enter the mailing address of the group’s leader if
publications will be mailed directly to the leader.
Other considerations for Extension Offices regarding the
youth and leaders reported through the use of this form:
 Mailing labels and lists will not be available.
 Youth will not be eligible for premiums.
 Various administrative groups and committees of
volunteer leaders may be reported using only the front
page of this form. Note that 4-H Council, Expansion
and Review, and 4-H Federation must be reported
using the Long Form.
Group Type
____ Community Special Interest
____ Community Short Term
Special Funding
Source
___ EFNEP
___ FNP
____ School Special Interest
____ After-School Special Interest
____ School Short Term
Integrated
Community
____ Yes
____ No
____ Camp-Day
____ Camp-Overnight
____ Indirect Administrative
____ Middle Management Administrative
Coalition
____ Yes
____ No
__________________________________________________________
Group Name
__________________________________________________________
Leader’s/Teacher’s Name (to receive publications if needed)
(_______)_____________ ____________________________________
Phone Number
County Name
__________________________________________________________
UPS Shipping address (to receive publications if needed)
_____________________________________
City
_________________
Zip
Federal law requires the collection of this information.
NEW LEADERS, TEACHERS, or ASSISTANTS
ALL LEADERS, TEACHERS, or ASSISTANTS
REPORT LEADERS FOR WHICH THIS IS THEIR ONLY CONTACT
WITH EXTENSION YOUTH THIS YEAR (SEPTEMBER 1–AUGUST 31)
REPORT ALL LEADERS PARTICIPATING
INCLUDING NEW LEADERS FROM COLUMN 1
GENDER:
ADULTS
(over 19)
GENDER:
Male
________
________
Female
________
________
YOUTH
(age 19 and below)
Total
Male
________
Female
________
Total
IN
THIS
GROUP,
ETHNICITY/RACE:
ETHNICITY/RACE:
American Indian or Alaskan Native
________
American Indian or Alaskan Native
________
________
Asian
________
Asian
________
________
Black or African American
________
Black or African American
________
________
Hispanic or Latino
________
Hispanic or Latino
________
________
Native Hawaiian or
Other Pacific Islander
Native Hawaiian or
Other Pacific Islander
________
_________
________
White
________
White
________
________
More than one race
_______
More than one race
________
________
Total
Total
____________________________________________________________________________________________________________________________
Issued in furtherance of Cooperative Extension Work, Acts of May and June 30, 1914, in cooperation with the U.S. Department of Agriculture, Dennis
Campion, 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.
revised 8/2004
NEW YOUTH/MCA
ALL YOUTH / MCA
IN THIS COLUMN, REPORT YOUTH OR MENTALLY CHALLENGED
ADULTS FOR WHICH THIS IS THEIR ONLY CONTACT WITH U of I
EXTENSION YOUTH PROGRAMS THIS YEAR (SEPTEMBER 1–
AUGUST 31)
IN THIS COLUMN, REPORT ALL YOUTH OR MENTALLY
CHALLENGED ADULTS PARTICIPATING IN THIS GROUP,
INCLUDING NEW PARTICIPANTS FROM COLUMN 1.
GENDER:
GENDER:
Male
________
Female
________
Total*
Male
________
Female
________
Total
ETHNICITY/RACE:
ETHNICITY/RACE:
American Indian or Alaskan Native
________
American Indian or Alaskan Native
________
Asian
________
Asian
________
Black or African American
________
Black or African American
________
Hispanic or Latino
________
Hispanic or Latino
________
Native Hawaiian or
Other Pacific Islander
________
Native Hawaiian or
Other Pacific Islander
________
White
________
More than one race
________
White
________
More than one race
________
Total*
Total
YOUTH PROJECT PARTICIPATION
RESIDENCE:
Farm (where agricultural income is derived)
_______
PROJECT NAME
Male
Rural/Small Town (under 10,000 or rural non-farm)
_______
____________________________________
_____
Medium Town (10,000-50,000 and their suburbs)
_______
____________________________________
____
_____
_____
Suburbs of the cities listed below or of St. Louis
_______
____________________________________
____
_____
_____
____________________________________
____
_____
_____
____________________________________
____
_____
_____
____________________________________
____
_____
_____
____________________________________
____
_____
_____
____________________________________
____
_____
_____
Cities over 50,000
_______
(Bloomington/Normal, Champaign/Urbana, Chicago, Decatur,
Joliet, Peoria, Rockford, Rock Island/Moline, or Springfield)
Female Pubs?
_____
_____
Total*
GRADE IN SCHOOL:
Kindergarten______
6 ______
12
_____
1 ______
7 ______Post HS Education
_____
2 ______
8 ______Pre-K/Not in School
_____
3 ______
4 ______
9 ______Mentally Challenged
Adults _____
10 ______
5 ______
11 ______
Total*
I certify that this group will not restrict or deny any person
membership or participation in its programs or activities because
of race, color, national origin, religion, gender, ancestry, marital
status, familial status, sexual orientation, or disability. Signing
this form also constitutes a request for use of the 4-H name and
emblem for educational purposes in accordance with regulations
and policies of University of Illinois Extension.
* Totals in all parts of this section must be the same.
Signature of Group’s Leader or County Extension Office Staff
____________________________________________________________________________________________________________________________
Issued in furtherance of Cooperative Extension Work, Acts of May and June 30, 1914, in cooperation with the U.S. Department of Agriculture, Dennis
Campion, 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.