4-H Summary Record

Instructions: Print out the form, fill out the the information, sign the form, and mail it to your local 4-H office. If you need help completing the Summary Record Form, there are instructions available.

Name _________________________________________

Street _________________________________________

Town/City _________________________________________

ZIP Code _________________

Phone (______)___________________

Name of Club/Group _________________________________________

Birth date _________________

This form needs to be signed each year by the member, parent and leader before it is submitted to the county office for judging. Each must review this document for accuracy before signing.

4-H Year	Age on 1/1	Member's Signature	Parent's Signature	Leader's/Volunteer's Signature	Judge's Signature

A.4-H Projects: List the 4-H year on the left and list the project(s) you have completed and included a record for during that year in the other columns.

4-H Year	Community Service Project	Leadership Project	Project (fill in name)	Project (fill in name)	Project (fill in name)

B. Community Service: Include what you have done to help your community, groups or individuals (not your relatives). Include community service done through groups other than 4-H such as school, church and other organizations.

4-H Year	Activity/What I Did	Who I Helped/Results	4-H/ School/Other

4-H Year	Activity/What I Did	Who I Helped/Results	4-H/ School/Other

C. Leadership: Include all leadership roles that you have assumed in 4-H such as offices you have held, leadership roles on committees and experiences as a junior leader. Include leadership experiences through groups other than 4-H such as school, church and other organizations.

4-H Year	Leadership Experience	Responsibility/What I Did	4-H/School/Other
4-H Year	Leadership Experience	Responsibility/What I Did	4-H/School/Other

D. Workshops/Conferences/Camps Attended: List those sessions that you have attended and summarize the most important things that you learned. Include those done through groups other than 4-H such as school, church and other organizations.

4-H Year	Workshop/Conference/Camp	What I Learned	4-H/ School/Other
4-H Year	Workshop/Conference/Camp	What I Learned	4-H/ School/Other

E. Communication Skills: List the presentations that you have given including speeches, visual presentations, illustrated talks, radio programs, T.V. appearances, video productions, news stories and articles written by you and any other type of presentations. Include presentations done through groups other than 4-H such as school, church and other organizations.

4-H Year	Type of Presentation	# Times Given	4-H/School/Other
4-H Year	Type of Presentation	# Times Given	4-H/School/Other

F. Youth Development; Events and Activities: List activities that you have participated in and identify the skills that you have gained through your participation in these activities. Skills may include communicating, decision making, coping, managing resources, learning about yourself and others and job related skills. Include activities done through groups other than 4-H such as school, church and other organizations.

4-H Year	Activity/Project	Skills Gained	4-H/School/Other
4-H Year	Activity/Project	Skills Gained	4-H/School/Other

G. Awards and Achievement: List recognition that you have received. Include awards received through school, church and other organizations. Summarize where possible.

4-H Year	Award Received	Achievement/Reason You Received Award

4-H Year	Award Received	Achievement/Reason You Received Award

H. 4-H Story: You must include your 4-H story, a written narrative which explains how 4-H has made an impact on your life or the lives of family or others.

I.Project Record(s): You must include at least one (maximum of 5) project records in your record book.

J. Support Materials: You may include additional materials to help tell your story. (maximum of 5 pages)

Please see instructions for information about how to complete each section, specific examples and assembly information.

 

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