4-H Sustainable Fisheries Club Enrollment - Cooperative Extension: 4-H - University of Maine Cooperative Extension

Name*

First Middle Last

Preferred Name (if different from legal name)

Email*

Enter Email Confirm Email

Primary Phone

Mobile Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County*

Birth Date*

School Grade*

Name of School*

Parent/Guardian 1 Name*

First Last

Parent/Guardian 1 Phone*

Parent/Guardian 1 Email*

Enter Email Confirm Email

Parent/Guardian 2 Name

First Last

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

Enter Email Confirm Email

Optional: Demographic Information

Please provide this optional information about the participating youth so that we may report to our federal partners.

Gender Identity

Hispanic Ethnicity

Racial Groups

Check all that apply.

Residence*

Family Member

Branch

Component

Name

This field is for validation purposes and should be left unchanged.