Kentucky 4-H Achievement Application



center-50000Kentucky 4-H Achievement Application1100000Kentucky 4-H Achievement Application46304304134NAME:______________________________________________________________COUNTY:____________________________________________________________DISTRICT:____________________________________________________________Applying for: _____Level ___Bronze ____Silver ____Gold ____Emerald Only Total Points: __________0NAME:______________________________________________________________COUNTY:____________________________________________________________DISTRICT:____________________________________________________________Applying for: _____Level ___Bronze ____Silver ____Gold ____Emerald Only Total Points: __________-36195280543000center5334000220110000022023495010414000 Kentucky 4-H Achievement ApplicationEligibility Requirements: Applicant must be eligible for Kentucky 4-H enrollment. Youth who have reached their nineteenth birthday before January 1 of current year are not eligible to apply for scholarships.4-H Applicant must have been a 4-H member in Kentucky or participated in the Kentucky Cooperative Extension 4-H Youth Development program for a minimum of one year.All reporting to be based on 4-H activities, events, projects unless noted.An activity/event/project/program may only be counted in one area. Personal Data:First Name: ____________________________________Last Name: _________________________Middle Initial: _____Address: __________________________________________________________________________________________City: ___________________________________________ State: _______ Zip: __________ Male: ___ Female: ___ Resident of Kentucky: ___Yes ___No County of Residence: ______________________________________________Age on January 1: ______ Birthday:________________________ Years in 4-H: ______ Years in Kentucky 4-H: _______Father’s/Guardian’s Name: ___________________________________________________________________________Mother’s/ Guardian’s Name: __________________________________________________________________________School: ___________________________________________________________________ Grade in School: __________Home Phone Number: ______________________________ Cell Phone Number: _______________________________Email Address: _____________________________________________________ Race: ___________________________Able to recite 4-H pledge: _________ 4-H Agent: _________________________________________________________-86906159679Emerald Applicants Only:Intended University/College/Technical/Secondary school of continued education: ____________________________Career goals: ___________________________________________________________________________________Expected Date of Graduation: ___________________________0Emerald Applicants Only:Intended University/College/Technical/Secondary school of continued education: ____________________________Career goals: ___________________________________________________________________________________Expected Date of Graduation: ___________________________Year:Favorite 4-H Project:Biggest 4-H Accomplishment:How will 4-H help you in the future:Personal Reference (other than 4-H Agent, 4-H Leader, or relative):Name: ________________________________________________________Relationship: ______________________Address: ______________________________________________________City: _________________State: _______Phone Number: __________________________________________________________________________________I certify that the information contained in this application is correct and truthfully reflects my personal and 4-H career records. I agree that, if any information within this application is found to be falsified in any way, my application will become null and void.I hereby authorize any person or entity to release to the Kentucky 4-H Youth Development Program and/or the Kentucky 4-H Foundation, or their authorized representatives, information concerning the subject matter of the statements I have made in this application. A copy of this authorization is agreed by the undersigned to have the same effect and force as an original. Any person, firm or entity releasing matters pursuant to this authorization is hereby absolved from any liability.I understand and agree that statements and/or quotes made in this application are the property of the Kentucky 4-H Youth Development Program and may be used for educational or promotional purposes.I certify that:This applicant has been enrolled in the Kentucky 4-H Youth Development Program for the _____ year,the application is complete, the work has been completed by the 4-H submitting the application, and all necessary attachments are included in the packet, andI recommend the applicant and his/her application be considered for a Kentucky 4-H Achievement Award.Member Signature: ________________________________________________________________________________Parent/Guardian: _________________________________________________________________________________Leader(s): _______________________________________________________________________________________Agent: _________________________________________________________________________________________-93980276860Gold Only: If selected to receive the Gold Achievement Award, how will you give back to your 4-H program and community after attending National Congress? _______________________________________________________________________________________________________________________________________________________0Gold Only: If selected to receive the Gold Achievement Award, how will you give back to your 4-H program and community after attending National Congress? _______________________________________________________________________________________________________________________________________________________Submission Date: ____________________________________ Submission Deadline:__________________-9334578740Emerald Only: If selected to receive the Emerald Achievement Award, how will you give back to your 4-H program and community after attending National Conference? _______________________________________________________________________________________________________________________________________________________0Emerald Only: If selected to receive the Emerald Achievement Award, how will you give back to your 4-H program and community after attending National Conference? _______________________________________________________________________________________________________________________________________________________General Application: ___ Personal Profile: ___ Resume: ___ Power Point: ___ Emerald Application: ____Category TotalsPoints Per CategoryLeadershipCitizenshipCommunication/MarketingCommunity ServiceParticipationTOTALDirections: In the 4-H Achievement program, there are 5 categories in which you can earn points.4-H’ers can record all qualifying entries from ages 9-18 years old (see 4-H age policy). Since points accumulate each year, it may be necessary to add additional lines to record entries. To add rows: click in the row above the area needed to add a row, click the ‘layout’ tab at the top, and click on ‘insert below’. While rows may be added, additional categories and/or areas may not be added. Limit any entries to no more than two lines of text on this application. An entry may include participation on the county, multi-county/district, state, and national on the same line.Some areas list examples of possible activities/events. The 4-H’er is not limited to these examples.Extended activities recorded are limited to 5 points per year.Entries recorded in 4-H Fair/Rally Day participation is limited to 1 point per division/project area entered (i.e. 1 point for photography entries regardless of the number of photography entries actually entered at the county fair, 1 point per division at state, etc.)For an entry recorded, the line must be completely filled out with all boxes completed.Totaling Points: Each category contains several areas in which entries can be recorded. At the end of each area, there is a place to enter that area’s totals. Totals should include all entries in that area from current and previous years. Record all area totals in the table at the end of each category. Do not enter zeros in any boxes, just leave those boxes blank.After the application is complete, record the category totals in the table above. LEADERSHIPOfficerYearOfficer position4-H clubC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsEX: 2011Secretary Happy Trails Horse Club11Total Officer PointsCommittee ChairYearCommittee chairedCommittee functionC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Committee PointsTeachingYearSubjectNumber in groupWhat group of 4-H’ers were taught?C1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Teaching PointsCounselorYearIssueNumber in groupSpecific OutcomesC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Counselor PointsDevelop materials (ie lesson plans, forms, and curriculum)YearType of materialHow distributedNumber receiving materialC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Development PointsAssisted LeaderYear4-H dutiesHow you helpedSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Assisting Points4-H PresentationYearType of presentationaudienceC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Presentation PointsMentorYearMentorship focusHow mentor helped 4-H’ersSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Mentor PointsCoordinateYear4-H dutiesWhat did you coordinateC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Coordinate PointsFacilitateYear4-H dutiesWhat did you facilitateC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Facilitate Points4-H Innovative IdeasYearNew ideaWas it implemented? How?C1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Innovation PointsExtended Leadership Activities Outside of 4-H (Limit of 5 points per year)Provide information about other significant leadership experiences you have had beyond your 4-H involvement:YearExternal leadership involvementGroupC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Extended Leadership PointsLEADERSHIP TOTAL: Total Officer PointsTotal Committee PointsTotal Teaching PointsTotal Counselor PointsTotal Development PointsTotal Assisting PointsTotal Presentation PointsTotal Mentor PointsTotal Coordinate PointsTotal Facilitate PointsTotal Innovation PointsTotal Extended Leadership PointsLEADERSHIP TOTAL341630020828000CITIZENSHIPVisit a state/national CapitolYearCapitalSkill/ knowledge gainedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Capitol Visitation PointsTour Kentucky Courthouses and/or other Kentucky government buildings YearCountyBuilding touredSkill/knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Courthouse/Buildings Visitation PointsAttend government/elected official meetingsYearCountyFunction attendedSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Meeting PointsCampaign for 4-H officesYearPosition soughtActivities performedSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Campaign PointsVisit historical landmarks in your community/state YearCountyLandmark touredSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Landmark Visitation Points4-H Innovative Ideas (ie. Create a scavenger hunt based on the historical sites visited; write a paragraph about a historical landmark for your Agent to publish in a newsletter, etc.)YearCountyActivity/audiencePurpose/ resultSkill/ knowledge gainedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Innovative Citizenship PointsExtended Citizenship Activities Outside of 4-H (Limit of 5 points per year)Provide information about other significant citizenship experiences you have had beyond your 4-H involvement:YearExternal citizenship activitySignificanceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Extended Citizenship PointsCITIZENSHIP TOTALTotal Capitol Visitation PointsTotal Meeting PointsTotal Campaign Points Total Landmark Visitation PointsTotal Innovative Citizenship PointsTotal Extended Citizenship PointsCITIZENSHIP TOTALCOMMUNICATION/MARKETING4-H Communication Contest (ie. Talks, Demonstrations, etc.)YearType of ContestSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Communication Contest Points4-H Radio/Television (Appearance, Public Service Announcements, Commercials)YearType of communicationAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Radio/Television PointsPrint Communication (Brochures, Newsletters, Displays)YearType of communicationAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Print Communication Points4-H Digital Media/Online Communication (Video, Web Mastering)YearType of communicationAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Digital Media Points4-H Public Presentations (Lectures, Master of Ceremonies, Informative Talk, 4-H Promotion)YearType of communicationAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Presentation Points4-H Recruit new member that joins a clubYearType of recruitmentAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Recruitment Points4-H Innovative IdeasYearExplain IdeaAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Innovative PointsExtended Communication/Marketing Activities Outside of 4-H (Limit of 5 points per year)Provide information about other significant communication experiences you have had beyond your 4-H involvement:YearType of External communicationAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Extended Communication PointsCOMMUNICATION/MARKETING TOTAL Total Communication Contest PointsTotal Radio/Television PointsTotal Print Communication PointsTotal Digital Media PointsTotal Presentation PointsTotal Recruitment PointsTotal Innovative PointsTotal Extended Communication PointsCOMMUNICATIONS/MARKETING TOTALCOMMUNITY SERVICEConduct a 4-H Community Service Project (ie recycling, beautification)YearType of service projectYour roleSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Community Service PointsJob ShadowingYearType of job shadowedYour roleSkill/knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Job Shadowing PointsGenerate Funds/Donation for 4-H (Prior approval by Agent required)YearType of fundraiserAudienceYour roleSkill/knowledge gainedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Fundraising Points4602480-6985C=County M/D=Multi county/DistrictS=State N=National00C=County M/D=Multi county/DistrictS=State N=NationalVolunteer Service for the Betterment of my CommunityYearType of projectAudienceYour roleSkill/knowledge gainedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Volunteer Service PointsInnovative Ideas in Community ServiceYearExplain IdeaAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Innovative Ideas PointsExtended Community Service Activities Outside of 4-H (Limit of 5 points per year)Provide information about other significant community service experiences you have had beyond your 4-H involvement:YearType of external serviceAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Extended Community PointsCOMMUNITY SERVICE TOTALTotal Community Service PointsTotal Job Shadowing PointsTotal Fundraising PointsTotal Volunteer Service PointsTotal Innovative Ideas PointsTotal Extended Community PointsCOMMUNITY SERVICE TOTALINVOLVEMENT/PARTICIPATION-5018179545Participation in 4-H 4-H Conferences4-H Trainings4-H Workshops4-H Events4-H Skill-a-thons4-H Activities4-H Club Meetings4-H Camps/Day camps00Participation in 4-H 4-H Conferences4-H Trainings4-H Workshops4-H Events4-H Skill-a-thons4-H Activities4-H Club Meetings4-H Camps/Day camps23869646354-H Programs4-H Shows4-H Contests4-H Tours4-H Exchange TripsRecord Book4-H Field Trips4-H Fair/4-H Rally Day 1 point per division/ project area entered004-H Programs4-H Shows4-H Contests4-H Tours4-H Exchange TripsRecord Book4-H Field Trips4-H Fair/4-H Rally Day 1 point per division/ project area enteredYearType of 4-H involvementItem / activityC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Participation PointsAssists 4-H AgentYear4-H duties1 time or on-goingNumber of participantsHow was 4-H agent helped?C1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Agent Assistance PointsSpecial 4-H Recognition/AwardsYearType of 4-H recognition/ rewardItem / activity being recognizedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Recognition PointsParticipate in a new 4-H Project Area from previous yearYear4-H project areaType of participationC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal New Project Area Points4-H Innovative Participation IdeasYearExplain IdeaAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Innovative Ideas PointsExtended Participation Activities Outside of 4-H (Limit of 5 points per year)Provide information about other significant participation experiences you have had beyond your 4-H involvement:YearType of external participationAudienceSkill/ knowledge learnedC1 ptM/D2 ptsS3 ptsN4ptsTotalPointsTotal Extended Participation PointsINVOLVEMENT/PARTICIPAITON TOTALTotal Participation PointsTotal Agent Assistance PointsTotal Recognition PointsTotal New Project Area PointsTotal Innovative Ideas PointsTotal Extended Participation PointsINVOLVEMENT/PARTICIPAITON TOTALRUBRIC:County Multi-County/District State National 12 3 4Clover Level 1: 25 pointsMinimum points required to achieve Level 1: 25 pointsClover Level 2: 50 pointsMinimum points required to achieve Level 2: 50 pointsClover Level 3: 100 pointsCan apply for Bronze: Plus Personal ProfileMinimum points required to achieve Level 3: 100 pointsClover Level 4: 150 pointsCan apply for Silver: Plus Personal ProfileMinimum points required to achieve Level 4: 150 pointsClover Level 5: 200 pointsCan apply for Gold: Plus Personal Profile and ResumeMinimum points required to achieve Level 5: 200 pointsEmerald Award:Top 10 Gold of current year – or – previous year Gold winnerGold requirements and Point Presentation ................
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