NEW MEXICO 4-H LEADER ENROLLMENT

2010-2011
Today’s Date County Name 4-H Club Name
BERNALILLO
I Live Where? (Check One) Telephone Number(s)
 Farm or Ranch  Town Gender
 Rural Email address:
 Male  Female
First Name Middle Initial Last Name
Alumni  Yes  No
Mailing Address # ______ Years as a 4-H Volunteer

City State Zip Code

Ethnicity (Check One)
 Hispanic or Latino
 Not Hispanic or Latino
Race (Check all that apply) Project Information (check One)
 White  First Year Leader
 Black or African American  Re-enroll
 American Indian or Alaskan Native  Corrections (Adding or dropping a
 Asian project)
 Native Hawaiian or Other Pacific
Islander

LEADER ROLES – Please circle all items below that best describe your 4-H responsibilities.
A. VOLUNTEER WORKING DIRECTLY WITH YOUNG B. VOLUNTEER WORKING FOR 4-H EXPANSION
PEOPLE USUALLY IN 4-H CLUBS 1. Public Relations & Recruitment (Newsletter, Radio,
1. Organizational Leader Newspaper Publicity
2. Assistant Organizational Leader 2. Advisory Group Leader
3. Project Leader 3. School Enrichment/Special Interest
4. Activity/Resource Leader (Demonstrations judging, Area of Responsibility
recreation, club communications) 5. Multi-Club Leader
Area of Responsibility Area of Responsibility
5. Teen Leader

Have you ever been: Y N

Convicted of a criminal offense?
Convicted for the use of or sale of drugs?
Hospitalized or treated for alcohol or substance abuse?
Convicted of child neglect or abuse?
Convicted of a DUI offense?
If YES to any of these, please explain or discuss with extension agent.

As a leader, I certify that this 4-H Club does not discriminate or limit membership because of race, sex, color, national origin,
religion, or handicap.
Signature of Leader _______________________________________________

Project Name of Project Send Projects Years in

Number (Yes/No) Project

FOR COUNTY USE ONLY

County Number Club Number Club Code Teen Leader
Ethnic Code Residence Code Date Entered