Name (First Last) 
Email Address
Street/PO Address
City   State    Zip
Sex:  Sex Male Female           Birthday: Month   Day   Year (4 digit year)
Grade: Grade Pre-K K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th College Not in School           School:
Including this year, how many years have you been in 4-H?
Parent/Guardian (who you live with) Name
Home Phone           Cell Phone: 
Where do your parent's work?
Where do you live? Residence? In the city of Greensburg In the county
What race are you, are you Hispanic?  Hispanic? Yes No
(you may select more than one)?
          white black Hispanic Am. Indian Asian/Pacific Islander
Do you have a disability? Disability? No Yes .      If yes, please describe.