Submit to the Extension Office or 4-H Council at least 30 days prior to the event

Club Name ______________________________________________________  Date _______________

Leader ____________________________________________________  Phone:  ________________ (H)

                                                                                                                                     ________________ (W)

Treasurer _________________________________________________   Phone:  ________________

Type of activity _____________________________________________  Date of _________________

                                                                                                                        Location________________

Describe the fundraising activity:

Intend to contact the following businesses:

Specific purpose for raising funds. How much do you need? What will it go toward? How many or who will benefit?

Person w/food handler’s card (if applicable):______________________________________________

I/we are familiar with the 4-H policy on fundraising and service in the name of 4-H. We understand it must have a specific purpose, we must raise funds through our own efforts and door-to-door selling is not encouraged.

Signature(s) ___________________________________________________________________________

You can mail this form to:  Lincoln Co. Extension Office, 4-H Dept., 29 S.E. 2nd St., Newport, OR 97365 or FAX to (541) 265-3887.  You can contact the 4-H Dept. by calling (541) 574-6534.

For reviewers (need at least one signature)

Approval granted ____ yes               ____ no

Agent signature: _________________________________________________________________         Date _____________

Council Approval: _______________________________________________________________           Date _____________