Sample Youth Group Enrollment Form by NASSdocs

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									          4-H/Expanded Food and Nutrition Education Program (EFNEP)
                        Youth Group Enrollment Form


Youth group name: _________________________________________________

Unit delivery mode: (circle one)

       A - Organized club
       B - Special interest, short-term program, or day camp
       C - Overnight camp (resident, primitive, or travel)
       D - School enrichment program
       E - Individual, mentoring or family learning
       F - School-age child care
       G - Instructional television or video

Address: _______________________________________________________

City: ____________________ State: _____ Zip: __________

Phone: _______________


Program start date: ___ /___ /___           Program end date: ___/___ /___


EFNEP Educator ID#: __________ EFNEP Educator name: ____________________

       Volunteer ID#: __________            Volunteer name: ____________________

       Volunteer ID#: __________            Volunteer name: ____________________

       Volunteer ID#: __________            Volunteer name: ____________________


Number of meetings: __________

Number of contact hours: __________

Number of youth in other 4-H programs: __________




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          4H/Expanded Food and Nutrition Education Program (EFNEP)
                   Youth Group Enrollment Form continued

Number of youth by age:

       _____ <1      _____ 4        _____ 8       _____ 12      _____ 16
       _____ 1       _____ 5        _____ 9       _____ 13      _____ 17
       _____ 2       _____ 6        _____ 10      _____ 14      _____ 18
       _____ 3       _____ 7        _____ 11      _____ 15      _____ 19

Age total: __________

Females and males by racial and ethnic background:

                                         Non-Hispanic        Non-Hispanic         Total
                                         Females             Males
White                                    _____               _____                _____
Black/African American                   _____               _____                _____
American Indian/Alaskan Native           _____               _____                _____
Asian                                    _____               _____                _____
Native Hawaiian/other Pacific Islander   _____               _____                _____
White and Black                          _____               _____                _____
White and Asian                          _____               _____                _____
White and American Indian/Alaskan Native _____               _____                _____
Total                                    _____               _____                _____

                                         Hispanic            Hispanic             Total
                                         Females             Males
White                                    _____               _____                _____
Black/African American                   _____               _____                _____
American Indian/Alaskan Native           _____               _____                _____
Asian                                    _____               _____                _____
Native Hawaiian/other Pacific Islander   _____               _____                _____
White and Black                          _____               _____                _____
White and Asian                          _____               _____                _____
White and American Indian/Alaskan Native _____               _____                _____
Total                                    _____               _____                _____

Race/ethnicity total: __________

Number of youth by place of residence:

       _____ Farm
       _____ Towns with population under 10,000 and non-farm
       _____ Towns and cities with population 10,000 - 49,999 and their suburbs
       _____ Suburbs of cities over 50,000
       _____ Central cities over 50,000

Place of residence total: _______


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