First Time Scholarship to State 4-H Congress

  Name:  											

  Address:  											

  City:	 							  Zip:  			

  Unit:  							 Birthdate: 
____________

  How long have you been in the 4-H program? ____________ (Month/year)

  Are you a member of a community club_____  or in-school club ____? 
(check one)

  How did you find out about Congress? 


  Describe how you will share your experience at Congress with youth and 
adults in your community.






  Agent Recommendation:




  Member Signature __________________________________

  Agent Signature ____________________________________

(Complete and attach to Congress Registration form)