West Virginia 4-H Member Enrollment

Transcription

1 West Virginia 4-H Member Enrollment PROFILE INFORMATION Club Name: Family Name: Family Phone: First Name: Middle Name: Last Name: Suffix: Preferred Name: of Birth: / / Gender: q Male q Female Years in 4-H: Age: MM DD YYYY All Star: q Yes q No : Charting Pin: q Yes q No : T-Shirt Size: q S q M q L q XL q XXL Primary Phone: Cell Phone: Correspondence Preference: q q Mail Do you wish to receive notices via text message: q Yes q No Provider: PARENT 1: First Name: Last Name: Cell Phone: Work Phone: Work Extension: PARENT 2: First Name: Last Name: Cell Phone: Work Phone: Work Extension: Home Phone: SECOND HOUSEHOLD: Send Correspondence: q Yes q No Correspondence Preference: q q Mail Family Last Name: Family First Name: Primary Phone: EMERGENCY CONTACT: Name: Phone: Contact Relationship:_ Cell Phone: 4-H County: continued

2 VOLUNTEER Did you serve in a leadership capacity in 4-H? q Yes q No (Example for youth: Junior Leader, Club Officer, etc. Examples for Adult: Chaperone, Community Club Leader, Project Leader, etc.) Are you a volunteer? q Yes q No Year Became Volunteer: ETHNICITY Are you Hispanic or Latino ethnicity? q Yes q No RACE Check all races that apply to you. If you selected Not Hispanic, you must select at least one option. q White q Black q Asian q American Indian or Alaskan Native q Native Hawaiian and Pacific Islander RESIDENCE q Farm q Town under 10,000 residents and rural non-farm q Town of 10,000 to 50,000 residents and its suburbs q Suburb city more than 50,000 residents q Central city more than 50,000 residents SCHOOL INFORMATION School County: School District: School Name: School Type: (i.e., home school, private school, public school) School Grade: 4-H MEMBER CODE OF CONDUCT 1. The purpose of the WVU Extension Service 4-H Program is to provide positive youth development. We believe in creating a safe learning environment that encourages four-fold youth development (i.e., Head, Heart, Hands and Health). All 4-H members participating in or attending club, county, regional, state and national programs, activities, events, shows and contests sponsored by the WVU Extension Service or representing 4-H at non-4-h events are required to conduct themselves according to the current West Virginia 4-H Member Code of Conduct and future modifications or amendments to the West Virginia 4-H Member Code of Conduct. 2. I am aware that my actions and decisions affect me and others. I acknowledge that I have been given a copy of the West Virginia 4-H Member Code of Conduct. I agree to conduct myself in accordance with the West Virginia 4-H Member Code of Conduct at all times. I understand that my failure to do so may result in the loss of privileges during 4-H programs, including involvement in future 4-H events or programs. My signature below demonstrates my agreement to abide by the West Virginia 4-H Member Code of Conduct, as well as any code of conduct established for a specific 4-H event or program I attend. Signature of 4-H Member I have read, reviewed and discussed the current West Virginia 4-H Member Code of Conduct with my child. I understand that my child will be expected to conduct himself/herself in accordance with the current West Virginia 4-H Member Code of Conduct and any future modifications or amendments at all times, and that failure to do so may result in the consequences stated in paragraph 2 above. I also understand that coordinators of 4-H programs, such as camps, overnight events and livestock shows, often establish specific expectations, guidelines and consequences, and should my child choose to participate in these events, he/she will be expected to review the rules and expectations for each event and follow them accordingly. Signature of Parent or Legal Guardian not required if member is 18 or older WVU EXTENSION SERVICE MEDIA RELEASE q I do not consent to the publication of the image and likeness of the above named participant to be videotaped, audio taped or photographed. q I hereby give my consent for the image and likeness of the above named participant to be videotaped, audio taped or photographed for the following uses: Educational/Instructional media Recruitment/Outreach media Development media Newsworthy media documentation I further authorize West Virginia University, WVU Extension Service and/or West Virginia University Hospitals, Inc. and their component parts to use this electronic media and/or photographs in any manner whole or in part. This waiver includes usage of this media in any way deemed appropriate, which may include electronic and photographical reproductions thereof for the production of educational, instructional, promotional or institutional advancement materials, which support the educational and outreach activities of West Virginia University. I hereby waive any right I may have to inspect or approve any use of this electronic media and/or photographs, and I release West Virginia University and its component parts from all liability which could result from its use. Signature of Parent or Legal Guardian (Required even if participant is 18 or older.) TRANSPORATION: Parent or Guardian Name (print here):. I give permission to the following individual(s) to pick up my child at the conclusion of this 4-H event or program: Name(s):_, _,

3 4-H PROJECTS: Put an (X) in the box for the project(s) you plan to carry this year. Club Name: ANIMAL SCIENCE (For beef, dairy, horse, sheep, swine, poultry, dog, rabbit, goat, pets, and cat projects, you must also select an animal record guide.) Livestock record guides are based on 4-H member s age as of Jan. 1 of the 4-H year. Please check: q Beginner (age 8-10) q Intermediate (age 11-13) q Advanced (age 14-20) q V et Science I The Normal Animal q V et Science II Animal Disease q Vet Science III Animal Health 1041 q Bite Into Beef (Beef 1) 1042 q Here s the Beef (Beef 2) 1043 q Leading the Charge (Beef 3) 1051 q Cowabunga! (Dairy 1) 1052 q Mooving Ahead (Dairy 2) 1053 q Rising to the Top (Dairy 3) 1061 q Giddy Up and Go (Horse 1) 1062 q Head, Heart and Hooves (Horse 2) 1063 q Stable Relationships (Horse 3) 1064 q Riding the Range (Horse 4) 1065 q Jumping to New Heights (Horse 5) q 4-H Horse Record Guide 1071 q Lambs, Rams and You (Sheep 1) 1072 q Shear Delight (Sheep 2) 1073 q Leading the Flock (Sheep 3) 1081 q The Incredible Pig (Swine 1) 1082 q Putting the Oink in Pig (Swine 2) 1083 q Going Whole Hog (Swine 3) 1101 q Scratching the Surface (Poultry 1) 1102 q Testing Your Wings (Poultry 2) 1103 q Flocking Together (Poultry 3) 1111 q Wiggles and Wags (Dog 1) 1112 q Canine Connection (Dog 2) 1113 q Leading the Pack (Dog 3) q 4-H Dog Record Guide 1121 q What s Hoppening? (Rabbit 1) 1122 q Making Tracks (Rabbit 2) 1123 q All Ears (Rabbit 3) 1131 q Getting Your Goat (Dairy Goat 1) 1132 q Stepping Out (Dairy Goat 2) 1133 q Showing the Way (Dairy Goat 3) 1135 q Just Browsing (Meat Goat 1) 1136 q Get Growing with Meat Goats (Meat Goat 2) 1137 q Meating the Future (Meat Goat 3) 1141 q Pet Pals (Pets 1) 1142 q Scurrying Ahead (Pets 2) 1143 q Scaling the Heights (Pets 3) q 4-H Pets Record Guide (List kind of pet ) 1151 q Purr-fect Pals (Cat 1) 1152 q Climbing Up! (Cat 2) 1153 q Leaping Forward (Cat 3) q 4-H Cat Record Guide q Self-Determined Animal Science RECORD GUIDES q 4-H Beef/Cow Heifer Record Guide q 4-H Beef/Cow Heifer Record Guide q 4-H Beef/Cow Heifer Record Guide q 4-H Breeding Goat Record Guide q 4-H Breeding Goat Record Guide q 4-H Breeding Goat Record Guide q 4-H Breeding Poultry Record Guide q 4-H Breeding Poultry Record Guide q 4-H Breeding Poultry Record Guide q 4-H Breeding Rabbit Record Guide q 4-H Breeding Rabbit Record Guide q 4-H Breeding Rabbit Record Guide q 4-H Breeding Sheep Record Guide q 4-H Breeding Sheep Record Guide q 4-H Breeding Sheep Record Guide q 4-H Dairy Cattle Record Guide q 4-H Dairy Cattle Record Guide q 4-H Dairy Cattle Record Guide q 4-H Dairy Goat Record Guide q 4-H Dairy Goat Record Guide q 4-H Dairy Goat Record Guide q 4-H Feeder Calf Record Guide q 4-H Feeder Calf Record Guide q 4-H Feeder Calf Record Guide q 4-H Market Beef Record Guide q 4-H Market Beef Record Guide q 4-H Market Beef Record Guide q 4-H Market Goat Record Guide q 4-H Market Goat Record Guide q 4-H Market Goat Record Guide q 4-H Market Lamb Record Guide q 4-H Market Lamb Record Guide q 4-H Market Lamb Record Guide q 4-H Market Poultry Record Guide q 4-H Market Poultry Record Guide q 4-H Market Poultry Record Guide q 4-H Market Rabbit Record Guide q 4-H Market Rabbit Record Guide q 4-H Market Rabbit Record Guide q 4-H Market Swine Record Guide q 4-H Market Swine Record Guide

4 10843 q 4-H Market Swine Record Guide q 4-H Purebred Swine Record Guide q 4-H Purebred Swine Record Guide q 4-H Purebred Swine Record Guide PLANT SCIENCE AND CROPS q Potatoes q Strawberry Planting q Strawberry Harvesting q Meet the Plants q See Them Sprout (Gardening Level 1) q Let s Get Growing (Gardening Level 2) q Take Your Pick (Gardening Level 3) q Growing Profits (Gardening Level 4) q Self-Determined Plant Science and Crops MECHANICAL SCIENCE q Starting Up (Tractor A) q Tractor Operations (Tractor B) q Moving Out (Tractor C) q Learning More (Tractor D) 1541 q Crank It Up (Small Engines 1) 1542 q Warm It Up (Small Engines 2) 1543 q Tune It Up (Small Engines 3) 1562 q Bicycling for Fun (Bicycle 1) 1563 q Wheels in Motion (Bicycle 2) 1571 q Magic of Electricity (Electricity 1) 1572 q Investigating Electricity (Electricity 2) 1573 q Wired for Power (Electricity 3) 1574 q Entering Electronics (Electricity 4) q Rockets Away Two-Liter Bottle q Rockets Away Solid Fuel Two-Liter Bottle 1601 q Measuring Up (Woodworking 1) 1602 q Making the Cut (Woodworking 2) 1603 q Nailing It Together (Woodworking 3) 1604 q Finishing Up (Woodworking 4) q Self-Determined Mechanical Science NATURAL RESOURCES AND ENVIRONMENT q Skynet Junior Scholars (Astronomy) 1711 q Spring Wildflowers 1712 q Summer and Fall Wildflowers 1731 q Teaming with Insects Grades 3-5 (Entomology 1) 1732 q Teaming with Insects Grades 6-8 (Entomology 2) 1733 q Teaming with Insects Grades 9-12 (Entomology 3) 1761 q Tree Identification 1762 q Follow the Path (Forestry 1) 1763 q Reach for the Canopy (Forestry 2) 1764 q Explore the Deep Woods (Forestry 3) q Trapping 1773 q Birds 1781 q Take the Bait (Sportfishing 1) 1782 q Reel in the Fun (Sportfishing 2) 1783 q Cast into the Future (Sportfishing 3) 1791 q Exploring Your Environment- Earth s Capacity 1792 q Exploring Your Environment- Ecosystems Services q Reduce, Reuse, Recycle q Self-Determined Natural Resources and Environment LEADERSHIP AND COMMUNITY INVOLVEMENT 2141 q Make Reading Come Alive (Grades 6 and Above) 2142 q My Leadership Journal (Grades 6-8) 2143 q My Leadership Portfolio (Grades 9-12) q My Leadership Journal Record Guide q My Leadership Portfolio Record Guide q Self-Determined Leadership and Community Involvement LEISURE AND CULTURAL EDUCATION 2211 q Hiking Trails (Outdoor Adventures 1) 2212 q Camping Adventures (Outdoor Adventures 2) 2213 q Backpacking Expeditions (Outdoor Adventures 3) 2247 q Recreation q Exploring 4-H, Your Family, The World or Arts q Self-Determined Leisure and Cultural Education HEALTH AND SAFETY q First Aid in Action (Health 1) q Staying Healthy (Health 2) q Keeping Fit (Health 3) q Self-Determined Health and Safety INDIVIDUAL AND FAMILY RESOURCES Management q My Financial Future Beginner Youth Notebook q My Financial Future Advanced Youth Notebook 3018 q Be the E (Entrepreneurship) Workforce Readiness 3021 q Build Your Future Youth Notebook Clothing 3041 q Under Construction (Sewing Expressions 1) 3042 q Fashion Forward (Sewing Expressions 2) 3043 q Refine Design (Sewing Expressions 3) Food Preparation 3061 q Cooking q Cooking q Cooking q Cooking 401 Personal Development 3111 q 4-H Charting A Journey Begun q Self-Determined Individual and Family Resources COMMUNICATIONS ARTS AND SCIENCES q Focus on Photography (Photography 1) q Controlling the Image (Photography 2) q Mastering Photography (Photography 3) q 4-H News Reporter q Self-Determined Communications Arts and Sciences MISCELLANEOUS q This Is 4-H (Any Age) q This Is 4-H: Philosophy and Traditions q Self-Determined Miscellaneous OTHERS WVU is an EEO/Affirmative Action Employer. Underrepresented class members are encouraged to apply. This includes: minorities, females, individuals with disabilities and veterans. The WVU Board of Governors is the governing body of WVU. The Higher Education Policy Commission in West Virginia is responsible for developing, establishing and overseeing the implementation of a public four-year colleges and universities. 4H17-102

5 West Virginia 4-H Member Code of Conduct While attending 4-H activities and events, I will: Obey all rules established by the local, state and national 4-H program, event/program facilities, and all local, state and federal laws. Conduct myself in a courteous manner with others, refraining from the use of profanity or language that is disrespectful and making sure my conduct and participation in 4-H projects, programs, exhibits and other 4-H or WVU Extension Service youth-sponsored activities is above all honest, courteous and fair. Conduct myself with good sportsmanship. I understand that a judge s decision is final. I will comply with directions of WVU Extension Service officials acting in the performance of their duties. Respect the authority of adult volunteers, youth leaders, WVU Extension Service staff and others in leadership roles. Refrain from possession, transport or use of firearms, bows and arrows, knives and other implements of harm except within the context of an approved shooting sport, archery or similar educational programs. Refrain from the use, transport or possession of alcohol, drugs or tobacco. I will not offer alcohol, tobacco products or illegal substances to other youth. If I encounter anyone using these substances, I will leave their presence immediately and report the incident to adult leaders or program staff. Not tamper nor use without permission, or otherwise harm clothing, belongings or other personal property of participants, staff or volunteers. I will be courteous to other individuals and their property. Respectfully use the facilities, equipment and grounds made available by the West Virginia 4-H or WVU Extension Service youth program. Remain in the appropriate assigned program areas at all times and dress appropriately for each event. I will not abuse any other 4-H or youth participant or volunteer by physical or verbal means. I will engage in respectful behavior toward my peers, being careful to avoid harassment, hazing, pranking and initiations that invoke humiliation, embarrassment, or targeting individuals or that may cause physical or mental harm to another. If I encounter anyone engaging in any of these activities, I will leave their presence immediately and report the incident to adult leaders or program staff. Make an effort to include all my 4-H and youth peers in activities. I will promote a spirit of inclusion and welcome individuals from all backgrounds. Respect local, state and national 4-H and WVU Extension Service program social media rules and guidelines, and refrain from creating, possessing or transferring any images that are illegal or disrespectful toward others or the 4-H or WVU Extension Service youth program. In addition, where appropriate, I will ask permission before I take or transfer images of those participating in 4-H or WVU Extension Service activities. I will communicate (oral, written and electronic) in an honest, respectful manner in all situations involving the 4-H or WVU Extension Service youth program. I will treat all animals with respect. I will provide appropriate care. My animal s appearance or its performance shall not be altered, except using generally accepted fitting and animal husbandry practices. Sanctions for misconduct relative to this 4-H and WVU Extension Service Member Code of Conduct can be requested from your local WVU Extension Office or online at Name (Keep for your records)