Tuesday Take Homes Registration

Tuesday Take Homes Registration

Please fill out a registration for each student participating.
Student Name *

First Name Last Name
Parent Name

First Name Last Name
Student Birth Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail *
example@example.com
Mobile Number *

Area Code Phone Number
Sign up for the rest of the summer.

Yes, please! No, thank you. Just this week!
Are you currently a member of 4-H? *

Yes No
If you are a 4-H member, you do not have to answer the following questions. If you selected no, the following questions are voluntary.
Gender
Grade
Residence

Farm Rural (pop under 10,000) Town (pop 10,000 - 50,000) Suburb (pop over 50,000) City (pop over 50,000)
Race

White Black or African American American Indian or Alaska Native Asian Native Hawaiian/Pacific Islander Other
Ethnicity

Hispanic Non-Hispanic Prefer Not to Answer
If have been participating in Tuesday Takes Homes, please rate your experience. We would love any of your feedback to better serve out community!
Additional Comments
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