2014/2015 Adams County 4-H Embryology Enrollment Form
Name of Program: Meet The Plants
Event Description: School Enrichment
Group Name: ______________________________
School: ____________________________
Date Completed: ____/____/________
Total Hours: ____
Leader Name: _____________________
County: ADAMS
City/State/Zip: _____________________________________________
Section 1: Adult & Youth
Volunteers
Adult Volunteers
Youth Volunteers
Participants
Section 2: Youth in
Program (Gender)
Male
Female
Participants
Section 3: Ethnicity
Hispanic
Non-Hispanic
Participants
Section 4: Race
White
Black
Am Indian/Alaska Native
Asian
Hawaiian/Pacific Islander
Hispanic
Other
Participants
Section 5: Residence
Farm
Town < 10K
Town 10K – 50K
Participants
Section 6: School
Grade
Not in School
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Post High School
Participants
Please attach a class roster with names.