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
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
Check here if a participant requires auxiliary aids & services due to a disability.
Extension Educator submitting registration:
County Extension Office complete address:
CES Phone number: City State Zip
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