4-H Enrollment Form

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4-H Enrollment Form

Coffee County 4-H

Email *

School Student Attends *

Student's Grade *

Pre-K

College

Student's First Name *

Student's Middle Name (or Initial)

Student's Last Name *

Home Street Address

City

Zip Code

Date of Birth *

YYYY

Gender

Female

Male

Clear selection

Student's Email Address

Student's Cell Phone Number (no symbols, just numbers) Please include area code

Home Phone Number (no symbols, just numbers) Please include area code

T-Shirt Size

XXL

XXXL

Other

Clear selection

Race (Check all that apply)

White

African American or Black

American Indian or Alaskan Native

Asian

Native Hawaiian or Other Pacific Islander

Ethnicity *

Hispanic or Latino

Non-Hispanic

Are either of your parents currently in the military?

Yes

Clear selection

Residence *

Farm

Rural (non-farm rural community)

Town (Douglas)

First name of parent/guardian #1 that you live with

Last name of parent/guardian #1 that you live with

Cell phone number of parent/guardian #1 (no symbols, just numbers) Please include area code

Email address of parent/guardian #1

First name of parent/guardian #2 that you live with

Last name of parent/guardian #2 that you live with

Cell phone number of parent/guardian #2 (no symbols, just numbers) Please include area code

Email address of parent/guardian #2

First name of parent/guardian that you DO NOT LIVE WITH

Last name of parent/guardian that you DO NOT LIVE WITH

Cell phone number of parent/guardian that you DO NOT LIVE WITH

Email address of parent/guardian that you DO NOT LIVE WITH

List any medical concerns the 4-H staff would need to know about.

Submit

Clear form

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