Indiana 4 HC ongress Registration Form 12 by J7G2UPN

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									                        2012 Indiana 4-H Youth & Adult Congress Registration Form
NOTE: 4-H Accomplishment Scholarship winners and their parents will make reservations directly with the Indiana 4-H Foundation.



                     Date: November 10, 2012                                                                    Due October 15
                          Mail this form with payment
                                                                                                                     COUNTY
                     Make check payable to :                  Indiana 4-H Foundation
                     Mail payment to:                         Indiana 4-H Congress Registration
                                                              c/o Steve McKinley, Extension Specialist
                                                              Department of Youth Development & Agricultural Education
                                                              615 West State Street
                                                              West Lafayette IN 47907-2053

                     Registration Deadline: October 15, 2012

                     Cancellation refunds must be postmarked by October 29


                     Delegates                                    MALE         FEMALE              Cost                 Total


                     Youth Delegates                                 0              0          $      25.00                       $0.00
                     Adult Delegates                                 0              0          $      25.00                       $0.00
                     Total # Delegates                               0              0                                          $0.00
                                                                                                                 Total payable to
     No limit on number of delegates attending per county                                                          Indiana 4-H
                                                                                                                   Foundation
                                                                                                                   Foundation
     Check here if a participant requires auxiliary aids & services due to a disability.


     Extension Educator submitting registration:

     County Extension Office complete address:



                                                                                                    IN

     CES Phone number:                                                            City             State                 Zip

            Email:




Use Extension Database (ED) electronic entry procedures
to register individual youth & adults.

Refunds will be given in full if notified in writing by October 29. No-shows forfeit registration fee.
Recommended grades for youth delegates are Grades 8-12.
Adult delegates include County Educators, Adult Volunteers, and Junior Leader Advisors.
     Purdue University is an equal oopportunity/equal access/affirmation action institution.                  10/6/12 5:46 AM

								
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