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					                                           Canadian 4-H Council
                                    National and International Programs
                                    Delegate Information Form
Please indicate which program you are submitting delegate names to:
(Please print or complete online using the TAB key to navigate)

    Citizenship Seminar (CitSem)                                               Skills and Thrills Conference (Skills)
    Washington Conference (Wash)                                               Garfield Weston U.K Exchange (UK)
    National 4-H Conference (NC)                                               National 4-H Leaders Conference (NVLC)

          (please provide name as it would appear on birth certificate / passport. ie. Katherine not Kathy)


City                                                      Prov./Terr. SELECT                                  Postal

Telephone (           )                              ext.                  Other (          )

E-mail Address:

Airport of Departure:                                                      Return Airport:

Departure Date:                                             am / pm        Return Date:                                         am / pm

Birthdate:       /    /                        Age:                                  Sex:       Male                  Female
              mm / dd / yy                    (as of program start date)

Languages Spoken:               English              French                Both                 Other

Citizenship Seminar Delegates:
          Please identify your Federal Member of Parliament:

          * If you are not sure, please indicate your Federal riding:

Any other Information you think is relevant:

The Canadian 4-H Council and Canadian 4-H Foundation protect your personal information by adhering to all legislative requirements with
respect to privacy. We use your personal information to provide services, to keep you informed about 4-H activities, for statistical and
research purposes, to satisfy government and regulatory obligations and we may contact you from time to time regarding new Canadian 4 -H
Council and Canadian 4-H Foundation initiatives . If at any time you wish to be removed from our database, simply contact us by phone (613)
234-4448, fax (613) 234-1112 or via our web site and we will gladly accommodate your request.

October 2010

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