Today's Date

First Name   Last Name

Address

Street 1   
Street 2   
City          , California
Zip Code 

Area Code   Phone Number

E-mail Address (Only if you check it regularly)

What School are you Attending

Grade Level
8th   9th   10th   11th   12th   College!

Your Birth date        Month January February March April May June July August September October November December         Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     Year 85 86 87 88 89 90 91 92 93 94 95 96

 How old will you be on December 31, 2007 13   14   15   16   17   18   19

What Club are you with? Non Member American Riding Club El Toro High Flyers Bonanza Canyon Bobcats Fountain Valley Cloverdales Fullerton FBS Irvine Mesa Charros Irvine Valley High Achievers Jordan Bobcats Jordan Jaguare La Habra Hilltoppers Lake Forest Superstart Mark Twain Steamers SAUSD Migrant Ed Little Cottonwood Mesa Goathill Go-Getters Orange Acres Backbreakers Orange Villa Buckarros Orange Valley Handlers Ortega Rangers Paws For Independence Rancho Capistrano Wranglers Rancho Carrillo Roadrunners Trabuco Trailblazers Yorba Linda Cloverleaf Yorba Linda Kountry Kulitivators Y24H Anaheim

Are you currently an officer in your club? I'm not an club officer this year President Vice-President Recording Secretary Corresponding Secretary Treasurer Historian Newsletter / Reporter Sergeant at Arms Webmaster Immediate Past President

What size t-shirt would you like?  T-Shirt Size Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X Large Adult XX Large

How may years have you been in 4-H?

What day of the month does your club have the business meeting.
(Example: First Monday of each month, September through August)

4-H CAMP EXPERIENCE

Number of years as a camper   Number of years as counselor (Including your CIT year)

List the activities you preferred as a camper and why

List your responsibilities as a counselor

Other Camp Experience (Church Camp, Outdoor Education, Scout Camps, B.L.T., State Leadership Conference, Etc.)

Rank each group of the following camp programs that are of interest to you and in which you could provide leadership if selected.  Mark your 1(favorite), 2 and 3 choices for GROUP 1 and your 1(favorite), 2 and 3 choices for GROUP 2.

Each year the counselors and adult staff select a timely and fun camp theme and plan all the camp activities and programs around the theme.  After giving this important topic of "theme" some thought, complete the following camp plan.  The demonstration of  your ability to develop a  plan is considered in accepting you for a position.

MY CAMP PLAN

Camp theme

Cabin name ideas

Craft Ideas

Special program or theme days

Guest speakers for training

Recreation Ideas

Theme requests for meals

Special campfire or evening activities

Other suggestions

Additional Information

Are there any activities that will conflict with attending counselor meetings (first Thursday of the month from 7:pm to 8:30 pm, counselor-training week-end which is held locally or 4-H Camps which is held at Camp Conrad, usually during the 2nd week of August.  

 Yes  or  No

 If yes, please tell us about the conflict you anticipate?

What are the real reasons for conducting 4-H Camp (besides fun)?

List any activities/organizations in which you participate, i.e. sports, band, yearbook, etc.

List any special training or experiences, i.e. first aid, lifesaving cert., babysitter's course.

List any hobbies, interest or special skills

REFERENCES

Please list two adults, other than your parents, whom could be called for reference on Your leadership and teaching skills and your responsibility and personal character.