4-H National Youth Summit on Agri

4-H National Youth Summit on Agri-Science
January 16-19, 2015
At the National Youth Summit on Agri-Science, high school students develop the skills and
knowledge needed for the challenges facing agriculture, food security and sustainability. National
4-H Council and National 4-H Youth Conference Center have partnered with agricultural scientists,
researchers, leaders, politicians, and advocates to host the National Youth Summit on Agri-Science.
It's a hands-on learning, educational experience led by experts in the agricultural community. This
Summit includes workshops, curriculum, tools, and visits to agricultural government and advocacy
agencies as part of the learning experience.
Cumberland County Delegate Application
Deadline: December 26th 2014
Thanks to the support of the 4-H Advisory Committee, we expect to send a delegation of up to 10
youth from Cumberland County 4-H to the 2015 Agri-Science Summit. Candidates must be high
school students in grades 9-12 as of September 2014, who did not previously attend the AgriScience Summit. 4-H Program Assistant Cyndy Hetzell plans to attend as chaperone. Participants
will be required to complete an application and registration form and contribute $100 toward the cost
of the trip. Youth interested in attending this National Youth Summit must complete and return their
paperwork and payment (money order payable to 4-H Advisory Committee ) by Friday,
December 26th to:
4-H Center, 291 Morton Avenue, Millville, NJ 08332
Attention: Julie Karavan, County 4-H Agent
4-H AGRI-SCIENCE SUMMIT - January 16th- 19th 2015
APPLICATION FORM & REGISTRATION INFORMATION
A completed application form must be received on or before Friday, December 26th 2014 in the Cumberland County 4‐H Office, 291 Morton Avenue Millville, NJ 08332. (Please Print or Type) First & Last Name __________________________________ Cell ___________________Home Phone _____________________ Parent Cell_____________________ Current Grade (as of September 2014) Sex: M F Date of Birth ____________________ Address ____ (Street) (Town) (Zip) Email ____________________________________ Parent’s Email_______________________________ In Case of Emergency Contact: Name____________________________________________ Telephone ___________________
Do you have any Food Allergy/Dietary Restriction? If so, please describe:______________________________________________________________________ _____________________________________________________________________________ Do you require any ADA, special aid/service requirements? If so, please describe______________________________________________________________________ _____________________________________________________________________________ Parent’s Signature Leader’s Signature____________________________ 1. What agri‐science projects or activities have you been involved with in 4‐H, school and/or community organizations? Please describe each activity. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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_____________________________________________________________________________________ 2. Why do you think you should be selected to attend the Agri‐Science Summit? _____________________________________________________________________________________
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_____________________________________________________________________________________ What do you hope to learn while attending The Agri‐Science Summit? _____________________________________________________________________________________
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_____________________________________________________________________________________ JK 12.14 4‐H Faculty/Staff Signature _______________________________ Date ________________________

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