North Carolina 4-H Youth Enrollment (Paper Form) The North Carolina 4-H Youth Development Program utilizes an “online” enrollment and registration system called 4-HOnline 2.0. Enrollment and Registrations should be completed online via the 4-HOnline 2.0 system. Paper copies are only allowed if an individual / family lacks internet access and or if English is a secondary language for the individual / family and usage of a translated paper version is preferred. NC 4-H Collects demographic information as part of our state and federal reporting procedures. *Paper forms will be manually entered into the 4-HOnline 2.0 system by the local 4-H program staff. Year: _____________ County:_______________________ FAMILY PROFILE INFORMATION Email: ________________________________________ Family Name: ___________________________________ Mobile Phone Number: (____)__________________ Address: _________________________________________________________________________________________________ Street Address City State Zip Code YOUTH MEMBER INFORMATION Youth Member Name:__________________________________________________________________________________ First Middle Last Preferred (if needed) Date of Birth: _______________ Years in Program: _________ Gender:  Female  Male  Gender Identity Not Listed  Prefer Not to Answer Grade in School: ________ Residence:  Farm _  Town under 10,000 people or rural non-farm  City 10,000-50,000 people Are you of Hispanic or Latino ethnicity?  Hispanic or Latino  City over 50,000 people  Suburbs of city over 50,000 people  Non-Hispanic or Latino  Prefer Not to State Race:  White  Black or African-American  American Indian or Alaska Native  Native Hawaiian or other Pacific Islander  Asian  Balance (other combinations)  Prefer Not to State Emergency Contact: ______________________________________________ / ____________________________ Full Name Relationship to member Contact Phone: ____________________ Contact Email: ______________________________________ North Carolina State University and North Carolina A&T State University commit themselves to positive action to secure equal opportunity regardless of race, color, creed, national origin, religion, sex, age, disability. In addition, the two Universities welcome all persons without regard to sexual orientation. North Carolina State University, North Carolina A&T State University, U.S. Department of Agriculture and local governments cooperating. Parent or Guardian 1: ___________________________________________ Phone Number: (____)___________________ First Name Last Name Parent or Guardian 2: ___________________________________________ Phone Number: (____)___________________ First Name Last Name School Name: _________________________________________________ School Type:  Charter School  Homeschool  Magnet / Specialized School  Private School  Public School  Special Education  Vocational Education Military Affiliation:  I have a Family Member Serving in the Military  I have a Parent Serving in the Military  I have a Parent Who Retired from the Military  I have a Parent who Served in the Military Branch of Service (if applicable):  Aire Force  Army  Coast Guard  DOD Civilian Branch Component (if applicable):  Active Duty  I have a Sibling who is Serving in the Military  No one in my family is serving in the Military  Marines  Navy  Not Applicable  National Guard  Reserves  Not Applicable Custody Release: You may be asked to present photo ID at check-out. This is for the participant's safety. Please be aware of this policy before picking up the participant. I hereby give permission for this participant to be allowed to leave the 4-H program after the activity; and if it is necessary for the participant to leave before the end of the program due to illness, injury, or behavioral issues; I hereby give permission for the participant to be released into the custody of: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Member’s T-Shirt Size:  Adult Small  Adult XL  Adult 4XL  Youth Large  Adult Medium  Adult 2XL  Youth Small  Youth XL  Adult Large  Adult 3XL  Youth Medium *This information is required for all federally assisted programs and is solely used for the purpose of determining compliance with Federal civil r

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