Salutation SalutationDr.Mr.Mrs.Ms.Miss

First Name

Last Name

Maiden Name (if applicable)

Address

City

State

Zip

Email Address

Phone

Which descibes your affiliation with 4-H? Which descibes your affiliation with 4-H?Former 4-H MemberCurrent 4-H VolunteerFormer 4-H VolunteerCurrent 4-H LeaderFormer 4-H LeaderOther

Please list Other 4-H affiliations

What years did you Participate in 4-H? (from/until)

Name of 4-H Club

County my 4-H Club located County my 4-H Club located Autauga CountyBaldwin CountyBarbour CountyBibb CountyBlount CountyBullock CountyButler CountyCalhoun CountyChambers CountyCherokee CountyChilton CountyChoctaw CountyClarke CountyClay CountyCleburne CountyCoffee CountyColbert CountyConecuh CountyCoosa CountyCovington CountyCrenshaw CountyCullman CountyDale CountyDallas CountyDeKalb CountyElmore CountyEscambia CountyEtowah CountyFayette CountyFranklin CountyGeneva CountyGreene CountyHale CountyHenry CountyHouston CountyJackson CountyJefferson CountyLamar CountyLauderdale CountyLawrence CountyLee CountyLimestone CountyLowndes CountyMacon CountyMadison CountyMarengo CountyMarion CountyMarshall CountyMobile CountyMonroe CountyMontgomery CountyMorgan CountyPerry CountyPickens CountyPike CountyRandolph CountyRussell CountySt. Clair CountyShelby CountySumter CountyTalladega CountyTallapoosa CountyTuscaloosa CountyWalker CountyWashington CountyWilcox CountyWinston County

4-H projects involved in

Awards/Honors in 4-H

Tell us a favorite memory

Occupation

Family

Are your children 4-H'ers? Are your children 4-H'ers? Yes No

Would you like to know about 4-H programs in your county? Would you like to know about 4-H programs in your county? Yes No

How would you like to continue to be involved in the Alabama 4-H and Youth Development Program? How would you like to continue to be involved in the Alabama 4-H and Youth Development Program? Make contacts on behalf of 4-H Assist with local 4-H programs in my county Assist/Support specific 4-H events or projects

Select County you would like to assist in Select County you would like to assist inAutauga CountyBaldwin CountyBarbour CountyBibb CountyBlount CountyBullock CountyButler CountyCalhoun CountyChambers CountyCherokee CountyChilton CountyChoctaw CountyClarke CountyClay CountyCleburne CountyCoffee CountyColbert CountyConecuh CountyCoosa CountyCovington CountyCrenshaw CountyCullman CountyDale CountyDallas CountyDeKalb CountyElmore CountyEscambia CountyEtowah CountyFayette CountyFranklin CountyGeneva CountyGreene CountyHale CountyHenry CountyHouston CountyJackson CountyJefferson CountyLamar CountyLauderdale CountyLawrence CountyLee CountyLimestone CountyLowndes CountyMacon CountyMadison CountyMarengo CountyMarion CountyMarshall CountyMobile CountyMonroe CountyMontgomery CountyMorgan CountyPerry CountyPickens CountyPike CountyRandolph CountyRussell CountySt. Clair CountyShelby CountySumter CountyTalladega CountyTallapoosa CountyTuscaloosa CountyWalker CountyWashington CountyWilcox CountyWinston County

Please list specific 4-H events or projects you wish to assist/support