4-H Family Mindfulness Workshop Registration
Thank you for your interest in this new 4-H opportunity! We look forward to providing your family with engaging resources, tools, and activities to support mental health and overall well-being. Following registration, an ISU Extension staff member will be in touch with a Zoom link.
Child Participant's Information
Child's Name
*
First Name
Last Name
Gender
*
Grade level in school
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Ethnicity
*
Hispanic
Not Hispanic
Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Other
Population of Residence
*
Rural area
Town
Suburb of City
City
Are they enrolled as a 4-H member?
*
Yes
No
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Would you like to register a second child?
*
No
Yes
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Second Child's Name
*
First Name
Last Name
Gender
*
Grade level in school
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Ethnicity
*
Hispanic
Not Hispanic
Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Other
Population of Residence
*
Rural area
Town
Suburb of City
Central City
Are they enrolled as a 4-H member?
*
Yes
No
Back
Next
Would you like to register a third child?
*
No
Yes
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Next
Third Child's Name
*
First Name
Last Name
Gender
*
Grade level in school
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Ethnicity
*
Hispanic
Not Hispanic
Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Other
Population of Residence
*
Rural area
Town
Suburb of City
Central City
Are they enrolled as a 4-H member?
*
Yes
No
If you have more than 3 children you'd like to register, please contact 4-H Youth Program Specialist, Tiffany Berkenes, at berkenes@iastate.edu.
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Adult Participant's Information
Adult 1
*
First Name
Last Name
Adult 1 Email
*
example@example.com
Adult 2 (if multiple are participating)
First Name
Last Name
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
Please Select
Adair
Adams
Allamakee
Appanoose
Audubon
Benton
Black Hawk
Boone
Bremer
Buchanan
Buena Vista
Butler
Calhoun
Carroll
Cass
Cedar
Cerro Gordo
Cherokee
Chickasaw
Clarke
Clay
Clayton
Clinton
Crawford
Dallas
Davis
Decatur
Delaware
Des Moines
Dickinson
Dubuque
Emmet
Fayette
Floyd
Franklin
Fremont
Greene
Grundy
Guthrie
Hamilton
Hancock
Hardin
Harrison
Henry
Howard
Humboldt
Ida
Iowa
Jackson
Jasper
Jefferson
Johnson
Jones
Keokuk
Kossuth
Lee
Linn
Louisa
Lucas
Lyon
Madison
Mahaska
Marion
Marshall
Mills
Mitchell
Monona
Monroe
Montgomery
Muscatine
O'Brien
Osceola
Page
Palo Alto
Plymouth
Pocahontas
Polk
Pottawattamie (East)
Pottawattamie (West)
Poweshiek
Ringgold
Sac
Scott
Shelby
Sioux
Story
Tama
Taylor
Union
Van Buren
Wapello
Warren
Washington
Wayne
Webster
Winnebago
Winneshiek
Woodbury
Worth
Wright
Phone Number
*
Please enter a valid phone number.
Currently, this is the only session we have space remaining.
*
4:00-5:00pm (English)
Our family would prefer to receive the resources:
*
Electronic file through E-mail
Printed document and Mailed
Please list any accommodations you need to ensure a positive experience.
Family Mindfulness Virtual Programming Permission
This is an Iowa State University Extension & Outreach/4-H program that will be co-presented by two ISU Extension staff members in a group of up to 15 families from across Iowa via Zoom. This workshop series will be held each Monday at the time you selected - December 7, December 14, and December 21, 2020. The sessions will not be recorded. By signing below, I give my permission for the youth listed on this registration to participate in this program via Zoom.
Signature
Clear
This institution is an equal opportunity provider. For the full non-discrimination statement or accommodation inquiries, go to www.extension.iastate.edu/diversity/ext
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