Putnam County 4-H Annual Summary

Putnam County 4-H Annual Summary

4-H Year: October 1, 20___________ to September 30, 20___________ Name_________________________________________________________ Age (as of Jan 1): ___________ Address______________________________________________________ Years in 4-H: _____________ Town: _________________________________________________________ Zip: ____________________ Level Achieved (Check One)

(See Goal Setting & Achievement Guide for Requirements for each award) ______ Got 4-H Award

______ Heart of 4-H Award _______ 4-H Grows Leaders Award

Cornell Cooperative Extension is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities.

*Please be sure to fill out all sections of the form, “My 4-H Story” is on the back page

4-H Clubs & Projects: Please list all 4-H Clubs & Projects you were actively enrolled in during the past year (New members please write ‘New Member’)

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MY 4-H EXPERIENCE Please list all Educational/Enrichment, Community Service, Leadership, Ambassador Roles & Public Presentations which you took you took part in this year. You may only list each project/activity once. Please see the “4-H Goal Setting & Achievement Guide” for more information.

I. Educational/Enrichment Activities & Events:  ____________________________________

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II. Community Service: (Name of Community Service Project)  ____________________________________

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III. Leadership Roles:  ____________________________________

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IV. 4-H Ambassador Activities / Public Relations:  ____________________________________

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V. 4-H Public Presentations and/or 4-H Teen Interviews: (Title & where presented) 

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Other participation: (List any other 4-H or non 4-H events or activities which you took part in that you have not already listed elsewhere in this annual summary (examples: Family Fun Barbecue, International Holiday Social, Family Fun Night))

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Achievement Documentation: (Please indicate what other documentation you are submitting with your Annual Summary) Project Records- Number Submitted______ Project Stories- Number Submitted______ 4-H Portfolio

Member Signature: ____________________________________________________

Date: ___________

Signature of Primary 4-H Leader: __________________________________________________________

*This form may be mailed to: Cornell Cooperative Extension/4-H * Terravest Corp. Park * 1 Geneva Rd * Brewster, NY 10509 Or Faxed to: 278-6761 FOR OFFICE USE ONLY: Date Rec’d by 4-H Office: __________ Revised 6/17 Cornell Cooperative Extension is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities.

My 4-H Story Please use this as a way to give us feedback on what we can do to improve the 4-H experience for all youth. My favorite parts of this year were:

I learned or improved the following skills:

I would be interested in 4-H clubs or programs like:

I would like to learn these skills next year:

Some things that could be improved upon or added to next year’s 4-H program are:

Revised 6/17