Youth Group Enrollment

Program Year: Date completed

This form is used to record group totals for youth involved in group 4H programs. This includes special interest sessions such as gun Location safety certification, school enrichment, individual study, and instructional TV. Participants of these programs need not be Project/Activity Project/Activity Code members of organized 4H clubs. For this reason, they may not all be included in the enrolled 4H member/leader file. All participants Leader/Teacher are however, counted for ES-237 statistics. Those participants who are 4H members or Number of Units Held Hours of Inst/Unit have been part of a previous group entry are (groups, classrooms, schools, etc) considered duplicates in this file.

Delivery Mode Male Female Units Participant’s (No Grade duplicates) 1. Community clubs < do not use > Kindergarten 2. In-school clubs 1st Grade 3. After-school clubs 2nd Grade 4. Military 4-H clubs 3rd Grade 5. Special Interest/short term 4th Grade 6. Overnight camping programs 5th Grade 7. Day camping programs 6th Grade 8. School Enrichment 7th Grade 9. Individual Study 8th Grade 10. School Age Child Care Education 9th Grade 11. Instructional TV/Video 10th Grade 12. Total participants (w/duplicates) 11th Grade 13. Total (without duplicates)* 12 Grade Post High School Not in school Participants/Residence (Non-duplicates only) Special Farm Total * Non-Rural: Under 10,000 Town & City: 10,000-50,000 Suburb: Over 50,000 City: Over 50,000 Total *

* The number of male plus female in line 13 must equal the totals Is this group in a racially YES NO recorded in residence chart, grade chart & the Hispanic total & Non- mixed community? Hispanic total (from back). Duplicates are male, female, or units (or groups) that have been part of a previous program or are enrolled in 4-H. Is this group integrated? YES NO

YOUTH PARTICIPANTS ** Hispanic Total ** Non Hispanic Total A B C D E F G H I J White

Black or African American

American Indian / Alaska Native

Native Hawaiian/other Pacific Island

White & Black

White & AI or AN

Black or AI or AN

White & Asian

Balance (other combinations)

HISPANIC Ethnicity: NOT HISPANIC or LATINO Ethnicity: A person of Mexican, Puerto Rican, Cuban, Central or All others South American, or other Spanish culture or origin, regardless of race

A or F) # Enrollment included White A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. B or G) # Enrollment included Black or Africa American A person having origins in any of the black racial groups of Africa. C or H) # Enrollment included American Indian or Alaskan Native A person having origins in any of the original peoples of North, Central, and South America, and who maintains tribal affiliation or community attachment. D or I) # Enrollment included Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, of the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. E or J) # Enrollment included Native Hawaiian or Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, Micronesia, the Northern Marianas or other Pacific Islands.

** This number must equal the total of numbers entered below.