4-H Need-A-Computer Application

4-H Need-a-Computer Application (5 points) PLEASE PRINT! Name

Address

City State Zip

Phone County ______

Age Grade Teacher

School

Do you currently have a computer? Yes No

Number of people in your household

Does anyone in your home have a computer? Yes No If yes, do you use it? Yes No

Check One: Senior 4-Her Junior 4-H’er Cloverleaf 4-Her

Please list a reference (i.e. minister, teacher, school counselor, etc. - not a relative) and ask them to complete the attached reference form and return by 12/04 or attach to this application. Name

How do you know this 4-H’er?

Reference Phone

Requirement: On an attached sheet of notebook paper, please write a one page essay on: “Why I want or need this computer”. This essay counts for 50 points of your score. APPLICATION CHECK-OFF LIST: Essay Attached (Value – 50 Points) Reference Form Attached or Mailed (Value – 40 Points) Completed Need-A-Computer Application ( Value – 5 Points) Completed 4-H Activities Form (Value – 10 Points) Signature of County 4-H Personnel, 4-H’er and Parent/Guardian ( Value – 5 Points)

 Return completed application, reference, and essay by (County Deadline) to: . Application must be signed by County Extension Agent, 4-H Associate, or 4-H Program Assistant.

 County will mail before 12/04/14 (State Deadline) to: Cheryl Varnadoe, Extension 4-H Specialist, Georgia 4-H, Hoke Smith Annex, University of Georgia, Athens, Georgia 30602

 Computers will be awarded by committee on the basis of need and total application scores. The decisions of the committee are final.

 Those selected to receive a computer will be notified by their County 4-H office. Computers will be picked up at 4-H Fall Forum at Rock Eagle by the county 4-H program. 1 of 2 4-H Need-a-Computer Application

 For more information, call Cheryl Varnadoe at 706-542-4444.

This program is sponsored by the Georgia 4-H Communications/ Technology Leadership Team.

List and describe any activities you have participated in with the 4-H club: (10 points) If you are a new member, list what you have done so far.

READ AND SIGN: I understand that if I am selected to receive a computer that it may not be sold for money or personal gain or given as a gift to others. I understand that it must be returned to my county 4-H office.

4-H Applicant’s signature

Parent/Guardian’s signature

Extension Agent, 4-H Associate or 4-H PA Signature

Additional Comments by 4-H Staff on this applicant:______2 of 2 4-H Need-a-Computer Application ______

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