Evaluation Form Template—4th-12th Grades
page 1 of 2
http://www.exnet.iastate.edu/Pages/y4h/evaluation/
2007 Southwest Iowa Junior 4-H Camp Leadership Team
4-H Youth Program
Evaluation Form
We are interested in what you learned by being involved in 4-H.
Section I Life Skills
Please mark the box that indicates what you think about the following.
As a 4-H Camp Counselor I have learned…
yesalways
usually
not
often
nonever
yes
no
1. 2to use new information I have learned. (1008)
1. 2the importance of protecting the natural environment.
. (3034)
4.
to act in a responsible manner when using natural
resources. (3030)
to think about possible alternatives before making a
decision. (2003)
to value the contributions of others. (6003)
5.
to be friends with people who are different from me. (6006)
6.
to contribute as a member of a team. (8007)
7.
to follow instructions as they are given to me. (8004)
8.
to accept responsibility for doing a job. (8008)
2.
3.
Section II My 4-H Camp Counselor Experience
Please mark the box that indicates what you think about the following.
9.
Adults in the 4-H program know how to work with kids. (2103)
10.
4-H helps me prepare for the future. (2116)
10.
In 4-H I have opportunities to practice my leadership skills. (2118)
Section III Additional information
I have been in 4-H for __(9201)
(a) 1-2 years
(b) 3-4 years
(c) 5-7 years
(d) 8-10
I am ___ years old.
(i) 16
(j) 17
(a) 18
(b) 19
(9202)
I am entering grade ___.
(i) 10
(j) 11
(a) 12
(b) college
(9203)
Iowa State University 4-H Youth Program – Patricia A. Hendricks
January 1999 (rev. 04-99)
D:\98938690.doc
Evaluation Form Template—4th-12th Grades
page 2 of 2
http://www.exnet.iastate.edu/Pages/y4h/evaluation/
I am _____.
(a)
(b)
(9204)
female
male
My residence during most of my I would describe myself as
4-H years is/was __. (9205)
___. (9206)
(a) farm
(a) Native American
(b) rural non-farm
(b) Asian American
(c) town under 50,000 pop.
(c) African American
(d) city over 50,000 pop.
(d) White/Caucasian
(e) Hispanic
(f) Racially mixed
Would you recommend 4-H to
a friend or family member?
(9207)
(a)
(b)
(c)
(d)
definitely would
probably would
probably not
definitely not
The most important thing I have gained from my 4-H Camp Counseling experience is
(9300)
The one thing I would change about the 4-H Camp Counseling program is
(9400)
Other comments I would like to make
(9500)
Name (optional):
Date:
County(ies):
Iowa State University 4-H Youth Program – Patricia A. Hendricks
January 1999 (rev. 04-99)
D:\98938690.doc