4-H School Enrollment Form

Teachers who use our 4-H Curriculum are required to complete our

4-H School Enrollment Form. Please fill out, sign and provide to the

OSU Extension Office.  Thank you!

Teacher: _________________________________________

School: __________________________________________

School Address: (city & zip) __________________________

________________________________________________

School Phone Number: ________________________

Number of years you have used 4-H materials in the classroom or

have been a 4-H leader (include this year): ________________

Student Information: The following sections must be filled out

completely in order for literature to be provided.  This information

is needed for statistical reporting.  Racial data is required by our

affirmative action policy. All information is kept confidential.

Number of boys: _______

Number of girls:  _______

Number of race:
____white ____ black ____American Indian ____Hispanic ____ Asian
Number by grade: 

____K ____1st ____2nd ____3rd ____4th ____5th ____6th

____7th ____8th ____9th ____10th ____11th ____12th 

4-H Project or curriculum used: _______________________________

I do not exclude, restrict or deny participation in 4-H programs or

activities because of race, sex, color, national origin, religious belief

or handicap.

____________________________
Teacher's Signature

Mail to: Coos County OSU Extension, 631 Alder St,

Myrtle Point, OR 97458

Or send back with borrow box.