Enrollment Form

LYON COUNTY COOPERATIVE EXTENSION SERVICE
P. O. BOX 36, 231 MAIN STREET
EDDYVILLE, KENTUCKY 42038-0036
Phone: (270) 388-2341 - FAX: (270) 388-4627
e-mail: DL CES Lyon@EMail.uky.edu or wparis@uky.edu

NAME OF 4-H CLUB_____________________________________________________________________

YOUR NAME___________________________________________ ________________________________
(Last) (First)

MIDDLE INITIAL___________		Male________		Female__________

ADDRESS_____________________________________________________________________

CITY__________________________________________ STATE_____________ ZIP________

DATE OF BIRTH_____/_____/_____     S.S. No. _______-_____-_________

SCHOOL______________________________________________________________ Grade___________

Parent's/Guardian's Name_______________________________________ Phone No. (Home)___________________

Parent's/Guardian's Workplace____________________________________ Phone No. (Work)___________________

RACIAL/ETHNIC GROUP (check one)
___ White
___ Black
___ American Indian/Alaskan
___ Hispanic
___ Asian/Pacific Islander

RESIDENCE (check one)
You live:
___ On a farm
___ Out in county or small town
___ In a town of 10,000-50,000 people

 Other 4-H Clubs you hold membership in:__________________________________________________

 If you have a disability, describe and list any accommodations needed:__________________________

_____________________________________________________________________________________

4-H ENROLLMENT FORM

4-H ENROLLMENT
FORM