1999 VIRGINIA 4-H CONGRESS REGISTRATION (return to Local Extension Office)

NAME__________________________________________________	

ADDRESS_______________________________________________

CITY_____________________STATE________ZIP_____________

PARENTS NAME_________________________________________

PHONE (HOME)_(_____)_________________(OFFICE)_(_____)____________

SOCIAL SECURITY NUMBER________________________________________________    

 4-H All Star?      ___Yes ___No			
 Will you be tapped this summer ___Yes ___No

RACE_____   GENDER_____   DATE OF BIRTH (youth only)_________________

4-H MEMBER___  VOLUNTEER___   EXT. AGENT _____   OTHER(explain)_____________

ADULTS ONLY  -- Prioritize committee preference 
(1 = first choice  5 = last choice)

___OPERATIONS   ___PROGRAM   ___HEADQUARTERS   ___FACILITIES   ___COMMUNICATIONS

ROOMMATE(optional)__________________________________

REGISTRATION CATEGORY       	    	COST    DUE	
____Full Fee				$120	$120	
____First Timers Scholarship		$120	$  60
____Unit Volunteer Scholarship		$120	$  70
____Beef Ambassador/Officer/
	Ambassador Scholarships		$120	$ 70
____One Day Only			$ 25	$ 25

T-SHIRT SIZE (circle size)  
  Medium            Large          Xlarge           Xxlarge

____Non-Competitive Delegate   ____Competitive Delegate

Tuesday Competitive Event Number _____
(If you are planning to participate in a state contest, please indicate
the number of that contest.  See page "Competition Areas")
                                    
                                    OR
Community Service Track                                                             

For Share-the-Fun Acts ONLY:
	Category _________________________________________
	Please list other members (if applicable) in your act
		______________________________
		______________________________

Note:  For the Share-the-Fun Acts, you are responsible for your own musical 
accompaniment/tape recorders (this does not mean pianos).
	
"If you are a person with a disability and desire any assistive devices, 
services or other accommodations to participate in this activity please 
contact Dorothy Freeman 540-231-6373, during business hours (8 am - 5 pm) 
to discuss accommodations 15 days prior to the event."