Mercer County 4-H New Member Interest Form

4-H New Member Interest Form

Fill out and we will be in touch with more details! We are excited to welcome you to 4-H!
Thank you for your interest in joining 4-H where you'll get to explore projects that interest you in more than 150 areas! From rockets to cooking, robotics to horticulture, sewing, visual arts, livestock, dog obedience, shooting sports and more!

Illinois 4-H is part of University of Illinois Extension. Our unit serves the counties of Henry, Mercer, Rock Island and Stark. You can join one of our many community clubs and be part of our 4-H family!

Fill out this form and we will put you in contact with one of our 4-H leaders who will let you know more about the club and the opportuntiies that await! You will enjoy fun activities, special events, community service projects, leadership opportunities, awards, scholarships, friendships, and more in 4-H!

We also have many workshops and special events that are open to all members. We look forward to having you as part of our 4-H family!

If you have any questions, please don't hesistate to contact 4-H educator Jennifer Peterson via email @ jpetersn@illinois.edu or call her at 309-932-3447.
Youth Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Gender
2nd Youth Name (if any)

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Gender
Parent/Guardian Name

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent E-mail
example@example.com
Phone Number
Additional Comments
Should be Empty: