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CLOVER BUDS
Please complete the following information about yourself and the group/class that you will be using the curriculum with. We do ask that once you have finished teaching and/or utilizing the curriculum to please send to your
parish 4-H office
(Louisiana) or to the
Louisiana 4-H State 4-H Office
(out of state) a completed
Louisiana 4-H Group Enrollment Form
.
Select your state
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Louisiana users, please select your parish
*
Acadia
Allen
Ascension
Assumption
Avoyelles
Beauregard
Bienville
Bossier
Caddo
Calcasieu
Caldwell
Cameron
Catahoula
Claiborne
Concordia
De Soto
East Baton Rouge
East Carroll
East Feliciana
Evangeline
Franklin
Grant
Iberia
Iberville
Jackson
Jefferson
Jefferson Davis
La Salle
Lafayette
Lafourche
Lincoln
Livingston
Madison
Morehouse
Natchitoches
Orleans
Ouachita
Plaquemines
Pointe Coupee
Rapides
Red River
Richland
Sabine
St. Bernard
St. Charles
St. Helena
St. James
St. John The Baptist
St. Landry
St. Martin
St. Mary
St. Tammany
Tangipahoa
Tensas
Terrebonne
Union
Vermilion
Vernon
Washington
Webster
West Baton Rouge
West Carroll
West Feliciana
Winn
Please select your primary role for using a LA 4-H School Enrichment curriculum.
*
School Administrator/Teacher/Educator
Civic or Community Organization (other than 4-H)
4-H Agent/Staff, or Volunteer
Other
Other
If representing a Civic or Community Organization outside of 4-H, what is the name of the organization?
First name
*
Last name
*
Email address
*
Phone number
*
What best describes your current relationship with 4-H?
*
Absolutely No Relationship
Previously Involved with the 4-H Program
Current 4-H Faculty./Staff Member
Some Previous Knowledge
Current Active Volunteer
Former 4-H Member
School/Organization Name
*
Street address
*
State
*
Zip
*
For which class(s) do you plan to use this content? Please list the class name(s). (Example: Quest for Success)
*
Grade level(s) that you will potentially reach with the LA 4-H school enrichment program(s) taught. Select all that apply.
*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
12th
Estimated total number of students that you plan to reach with this content
*
Please list the percentage of male students and female students (based on total number of students entered) that you are EXPECTING to reach with the program below.
Male
*
Female
*
Gender must equal 100%
0
Calculate
Please complete the PROJECTED PERCENTAGE of student ethnicities (based on total number of students entered above) to be reached below.
Type 0 for any options that do not apply for your students.
% Hispanic or Latino
*
% of
NON
Hispanic or Latino
*
Gender must equal 100%
0
Calculate
Please complete the PROJECTED PERCENTAGE of student races (based on total number of students entered above) to be reached using the form below. Type 0 for any options that do not apply for your students.
% American Indian/Alaskan Native
*
% Asian
*
% Black or African American
*
% Caucasian or White
*
% Native Hawaiian or Pacific Islander
*
Gender must equal 100%
0
Calculate
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