Name_______________=

= &nb= sp; = Last = &nb= sp; = First = &nb= sp; = &nb= sp; Middle initial

Mailing Address____________________________________________________________________= ___________

City___________________________________________= ___________State____________Zip________________

Number of years as a = 4-H Volunteer: (include this year)_____ Community/ School:________________________________________=

Gender: &nb= sp; = Racial Group<= /u>:= &nb= sp; = Residence:=

______ Male &nb= sp; = ______ White &= nbsp; &nbs= p; &= nbsp; <= span style=3D'font-size:10.0pt;font-family:"Arial Narrow";mso-bidi-font-family:A= rial'>______ Farm &nb= sp;

______ Female&n= bsp; = ; ______ Black or African American &nb= sp; = ______ Towns and rural non-farm =

= &nb= sp; = = ______ Native American or Alaskan Native &= nbsp; ______ City of 10,000 to 50,000 =

Ethnicity:= = = ______ Asian or Pacific Islander = ; &n= bsp; ______ Suburb of city over 50,000 &n= bsp;

______ Hispanic = ; &n= bsp; ______ More than one race = &= nbsp; &nbs= p; ______ City of 50,000 or more = &nb= sp;

______ Not Hispanic &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp;

= &nb= sp; = &nb= sp; = &nb= sp; = = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; =

Role(s): _________________________________ Committ= ee(s) __________________________________= __

= &nb= sp; = &nb= sp; = &nb= sp; see back for both

= = &nb= sp;

Phones: Description	Area Code	Number	Extension

E-mail ___________________________________________________________________________= ___________

Club __________________________________________________________ ____________________________=

= club name = &nb= sp; = = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = club number

Projects you lead (see project identification codes on the back)<= /span> = &nb= sp; Description and Code required; Level and Phase = as appropriate.

Description	Code	Level	Phase

ADULT VOLUNT= EER EXPECTATIONS

The Oregon State University Extension Service strives to provide quality leader= ship for youth participating in 4-H programs.&n= bsp; The opportunity to work with youth is a privileged position of trust that should be held only by those who are willing to demonstrate behaviors = that fulfill this trust. The follo= wing behavior expectations are provided for volunteers working in the OSU Extens= ion Service 4-H Youth Development Program.

1. Treat others in a courteous, respectful manner demonstrating behavio= rs appropriate to a positive role model for youth.

2. Abide by policies and guidelines of the Oregon State University Extension Service state and county 4-H programs.

3. Obey all laws of the locality, state, and nation, including those related to use= of illegal substances, or use of firearms.

4. Make all reasonable effort to assu= re that 4-H youth programs are accessible without regard to race, color, relig= ion, sex, sexual orientation, national origin, age, marital status, disability, = and disabled veteran or Vietnam-era veteran status.

5. Recognize that verbal, sexual, phy= sical abuse, and/or neglect of youth is unacceptable either within or outside the= 4-H Youth Development Program. Re= port suspected abuse.

6. Treat animals humanely and teach 4-H youth to provide appropriate an= imal care.

7. Operate machinery, vehicles and ot= her equipment in a safe and responsible manner, and only with a valid operator’s license and the legally required insurance coverage.<= /o:p>

8. Handle fund raising and finances in an ethical manner.

9. Do not consume alcohol while respo= nsible for youth in 4-H activities nor allow 4-H youth participants under your supervision to consume alcohol or illegal substances.

· I have read, understand and agree to the OSU Extension Service 4-H Adult Volunteer Expectations.

· I have read and understand the information contained in the publication "= ;For the Well-being of Youth and Adults" (4-H 0258L) and agree to follow the adult/youth interaction-barriers to abuse guidelines contained in this publication.

· Use my name, hometown, image and voice on videotape, audiotape, film, photograp= h, or in any other medium, including the World Wide Web for educational, fundraising, or promotional purposes.

______________________________________ = ______________________________________=

Signature = &nb= sp; = &nb= sp; = Date

&nbs= p;	ROLE CODES	422	Weather
CC	Community Coordinator	423	Marine Science*
LC	Community Club Volunteer	431	Energy
PC	Project Club Volunteer	441	Forestry*
AL	Activity Volunteer	442	Range Science/Native Plants
RL	Resource Volunteer	443	Wildlife
ET	Teacher (School Enrichment)	451	Outdoor Education/Recreation
SI	Special Interest Group Volunteer	452	Challenge
PO	Public Official	460	Shotgun*
SC	SACC Contact	461	Archery*
SP	School Principal/Contact	462	Rifle*
CS	Camp Staff	463	Pistol*
DS	Donor/Supporter		Nutrition and Health=
	COMMITTEE CODES=	503	OFNEP
AC	Auction Committee	511	Foods and Nutrition*
AMC	Ambassador Committee	512	Food Preservation*
CC	Computer Committee	513	EFNEP*
CPC	Camp Committee	520	Health
DC	Dog Committee	521	Fitness and Sports
EAC	Expressive Arts Committee	522	First Aid/CPR
ERC	Expansion and Review Committee	523	Vision Education
FC	Fair Committee	531	Safety
FRC	Fashion Revue Committee	532	Tractor/Machinery Certification*
HC	Horse Committee	533	Search and Rescue
HEC	Home Economics Committee	534	Bicycle Safety*
HOC	Horticulture Committee	535	Auto Safety
IC	International Committee	536	ATV Safety
K3A	K-3 Adventures Committee		Personal Development= and Leadership
LC	Livestock Committee	611	Career Exploration
LEC	Leaders Executive Committee	612	Economics, Business & Marketing
MSC	Mechanical Science Committee	620	Leadership Development
NSC	Natural Science Committee	621	Junior Leadership*
OC1	Other 1 List	623	4-H Ambassador
ODC	Outdoor Challenge Committee	631	Camp Counselor
OYT	Older Youth/Teen Committee	641	Leisure Education
RC	Recruitment Committee	651	Hobbies and Collections
RGC	Recognition Committee		Plants and Animals
SAC	Small Animal committee	710	Agriculture in the classroom
UC	Urban Committee	711	Crops
VPC	Visibility and Promotion Committee	712	Gardening, Vegetables & Herbs*
	PROJECT CODES= (statewide curricul= um available*)	713	Gardening, Flowers & Ornamentals*
	Citizenship and Civic Education	714	House Plants
110	Citizenship*	715	Ornamental Horticulture
120	Cultural Education	716	Container Gardening
130	World Citizenship/International Programs	721	Beef*
	Communications and Expressive Arts	731	Poultry*
211	Public Speaking*	732	Pigeons*
212	Creative Writing	741	Dairy Cattle*
221	Clowning	751	Horse and Pony*
222	Dance	761	Rabbits*
223	Drama	762	Cavies*
224	Music	763	Dogs*
231	Art*	764	Guide Dogs
235	Ceramics*	765	Cats
236	Cake Decorating	766	Small Animals*
237	Art - Rubberstamping	771

Name___________________________________________________= ____________________________________

Name_______________=