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STAND STRONG

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 *

Louisiana users, please select your parish *

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? *

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. *

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

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

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

1st	2nd	3rd	4th
5th	6th	7th	8th
9th	10th	11th	12th 12th