4-H National Leader Application Form

VOLUNTEER LEADER APPLICATION FORM

INSTRUCTIONS:
     Listed below are the 2002/2003 National 4-H Travel Opportunities available to all Volunteer Leaders.  Please complete both sides of the following application form and return it to:

    NB Council 4-H Office
    267 Connell Street, Unit 5
    Woodstock, NB
    E7M 1L2

The deadline for applications is 4:30pm on November 30^th, 2002.

DELEGATE PROFILE:

NAME: ____________________

CLUB: ______________________

TELEPHONE NUMBER:
HOME (___)___-_____
WORK (___)___-_____

ADDRESS: _______________________________

POSTAL CODE: ____-____

PRESENT OCCUPATION:_____________________

NUMBER OF YEARS AS A VOLUNTEER 4-H LEADER: _____________

PREFERRED AIRPORTS:
1. _______________
2. ________________

DO YOU SMOKE? YES ____ NO ____

LANGUAGES:
ENGLISH ______
FRENCH ______
BILINGUAL _______

ATTENDED/CHAPERONED ANY 4-H CONFERENCES? YES ___ NO ___

IF YES, PLEASE STATE WHICH ONE: _________________________

TRAVEL OPPORTUNITIES:
Please rank in order of preference.

NATIONAL LEADERS CONFERENCE
(Toronto, 2002)       _____

CHAPERONE MEMBER'S CONFERENCE 
(Toronto, 2003)    ______

CHAPERONE CITIZENSHIP SEMINAR
(Ottawa, 2003)             ______

CHAPERONE YOUNG SPEAKERS FOR AGRICULTURE
(Toronto, 2002) (If needed)    ______    

* PLEASE ANSWER THE FOLLOWING QUESTIONS USING ADDITIONAL SHEETS OF PAPER FOR QUESTIONS 5 – 9.

BACKGROUND INFORMATION:

1. WHAT IS YOUR AGE?

______ Under 20 ______ 31 – 40 ______ 51 – 60

______ 21 – 30 ______ 41 – 50  ______ Over 60

2. WHAT IS THE APPROXIMATE NUMBER OF MEMBERS IN EACH AGE GROUP THAT YOU DEAL WITH REGULARLY?

______ Under 10 ______ 10 – 12 ______ 13 – 16

______ 17 – 19 ______ Over 19

3. DO YOU OR HAVE YOU HAD 4-H AGED CHILDREN?

_______ YES  ______ NO

  IF YES, WERE THEY INVOLVED?  ______ YES ______NO

4.  WERE YOU EVER A 4-H MEMBER?
______ YES ______ NO

  IF YES, HOW MANY YEARS? _______________________

5.  IN WHAT AREAS OF 4-H LEADERSHIP HAVE YOU BEEN INVOLVED? (GENERAL OR OVERALL)

 PROJECT LEADERSHIP AREAS?

6.  WHAT 4-H ACTIVITIES HAVE YOU PARTICIPATED IN AS A 4-H LEADER/MEMBER? (AT ANY LEVEL)

7.  WHAT SPECIAL 4-H RESPONSIBILITIES HAVE YOU ACCEPTED     

BEYOND THE CLUB LEVEL?

8.  WHAT ARE SOME SPECIAL ACTIVITIES OR HOBBIES YOU ENJOY OR ORGANIZATIONS IN WHICH YOU ARE INVOLVED?

    COMMENTS? (TIME CONSTRAINTS, ETC.)