Project In A Box Sign Up for Non-4-H members with Payment by Check

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Fill out this form for EACH household which will be utilizing the Project In A Box. If your household has more than 3 youth who will be using the box, please fill out this form again to include the additional participants. Thank you!

Household Last Name: *

Which Box Would You Like to Reserve? *

Energy

Kitchen Science

Jewelry Making

Knitting Box

Painting 1

Painting 2

Camp Cooking

Clay

Dessert Decorating

Fishing

What date would you like to pick up your box? Be sure you looked at the Project In A Box web page for the most current list of days when the box is available. *

First and last name of Youth Participant 1 who will be using the Project In A Box: *

Youth Participant 1 Race (this question is required by UW-Madision, Division of Extension): *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Prefer Not to Indicate

Other:

Required

Youth 1 Participant Ethnicity (this question is required by UW-Madison, Division of Extension): *

Hispanic or Latino

Not Hispanic or Latino

Prefer Not to Indicate

Other:

Required

First and last name of Youth Participant 2 who will be using the Project In A Box (if not applicable, leave blank):

Youth Participant 2 Race (this question is required by UW-Madision, Division of Extension) - If not applicable, leave blank:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Prefer Not to Indicate

Other:

Youth Participant 2 Ethnicity (this question is required by UW-Madison, Division of Extension) - If not applicable, leave blank:

Hispanic or Latino

Not Hispanic or Latino

Prefer Not to Indicate

Other:

First and last name of Youth Participant 3 who will be using the Project In A Box (if not applicable, leave blank):

Youth Participant 3 Race (this question is required by UW-Madision, Division of Extension) - If not applicable, leave blank:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Prefer Not to Indicate

Other:

Youth Participant 3 Ethnicity (this question is required by UW-Madison, Division of Extension) - If not applicable, leave blank:

Hispanic or Latino

Not Hispanic or Latino

Prefer Not to Indicate

Other:

Household Email Address: *

Household Phone Number: *

Household Address (where box will be located): *

Does anyone in your household require an accommodation to participate in this activity? (If yes, please contact Bonnie Tillman at 715-365-2750 or bonnie.tillman@wisc.edu and let her know of your accommodation request. Thank you! *

Yes

How did you hear about this activity? *

School

Library

Newspaper

Radio

Facebook

Friend

Online

Other:

I agree to write a check for $10 written out to "UW-Extension Oneida County" and give it to 4-H staff at the time of pick-up or mail it to UW-Extension Oneida County, 5350 College Dr., PO Box 518, Northwoods Center, Rhinelander, WI 54501, before I pick up my Project In A Box or I will not receive a Project In A Box. I also agree that faulty or bounced checks will receive the same penalty as if received by an Oneida County government department. *

Yes, I have read this and understand this and I agree.

I need more information.

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