APPLICATION FOR ADULT CHAPERON

TRIPS and EVENTS

What trip/activity/event are you applying for(DC, etc)_________________________

NAME:______________________________________________________________________

ADDRESS:___________________________________________________________________

PHONE #   ______________________________      4-H CLUB: _________________________

1.  List your 4-H involvement at the club level

  

 

2.  List your 4-H involvement at the county level

 

 

3.  List other involvement or responsibilities you have with youth

 

  

4.  What other community organizations are you involved with

 

 

 

5.  Please list any special qualifications you have for this job

     (first aid, etc)

 

  

6.  Are you willing to help plan the next trip?  In what capacity?

 

  

 

7.  Please write a brief paragraph stating why you would like to chaperon this group of youth and what you hope to bring back to Valley County.

 

 

 

 

We would like you to make a report at a 4-H Council Meeting after the trip.

  

Signature:________________________________Date: ___________________________