Missouri Citizenship Washington Focus 2004
4-H Missouri Citizenship Washington Focus 2019
Delegate Application
Please print in ink or type.
Last Name____________________ First Name ___________________ Middle Initial_____
Male____ Female____ Name Tag Preference______________ Birthdate___-___-___
Address__________________________________ City_______________ Zip___________
County________________________ Social Security _______ -_____-________
Grade in School, Jan. 2019_________ Polo Size AS AM AL AXL AXXL
Delegate’s Home Phone (_____) ______________ Delegate’s Cell Phone (_____) ______________
Delegate’s Email Address______________________________________
Parent/Guardian’s #1 Name_______________________________________________________________________________
Parent #1 Address (if different than yours)_________________________________________________________________
Parent #1 Home Phone (____) ________________ Parent #1Cell Phone (____) __________________
Parent #1 Email ___________________________________
Parent/Guardian’s #2 Name_____________________________________________________________________________
Parent #2 Address (if different than yours)________________________________________________________________
Parent #2 Home Phone (_____) ____________ Parent #2 Cell Phone (_____) ______________
Parent #2 Email________________________________________
Your U.S. Congressional Representative __________________________________________________________________
Special Dietary, Physical or Other needs __________________________________________________________________
Why do you want to attend Citizenship Washington Focus?
What do you hope to gain from this experience and how do you plan to share this information when you return home?
List what you would consider your most valuable leadership experiences on the club, county, regional and or state level.
Have you participated in any government classes, activities or organizations?_____ If so, explain:
List musical or other talents you would be willing to share on our trip:
What types of travel experiences have you had?
As parent/guardian of _______________________________, I understand that he/she is applying to attend the 2019 Citizenship Washington Focus trip to Washington, D.C., Chevy Chase, Maryland, Baltimore and New York City. I have read the information and policies stated in the 2019 promotional flyer and understand that all payments must be made on time. I also understand and accept the cancellation policies provided.
___________________________________________________________________________________Date____________
Parent/Guardian #1 Signature
_________________________________________________________________________________ Date_______________
Parent/Guardian #2 Signature
Return application to the Pike County Extension Center, 115 W Main, Bowling Green, MO 63334
by December 3, 2018 with a check of $500 made out to the Pike County Extension Council .
4-H Citizenship Washington Focus
June 22 –July 1, 2019
Washington, D.C.,
Fort McHenry and New York City
Citizenship Washington Focus (CWF) is a 4-H leadership program for high school youth ages 15-18 from across America. Thousands of young people come to the National 4-H Youth Conference Center, near Washington, D.C., every summer to participate in a week-long program that enriches the lives of young people through
activities that broaden their appreciation and respect for themselves and others.
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Attach current photo here.
[pic]
Learn Leadership,
Live History,
Explore Your Nation!
Saturday, June 22 Board chartered bus to travel to D.C.
Hotel stay in route
Sunday, June 23 - Saturday, June 29 Citizenship Washington Focus
• Lodging at the National 4-H Youth Conference Center, Chevy Chase, MD
• Tour National Monuments, the United States Capitol, Smithsonian, Arlington National Cemetery, Dinner Theatre, National Archives and Mt. Vernon
• Meet elected officials
• Leadership Training & Fun!
Saturday, June 29 More D.C., Fort McHenry and Baltimore
Sunday, June 30 New York City, NY
Top of the Rock, 9/11 Memorial, Statue of Liberty Harbor Tour, Central Park and Times Square
Monday, July 1 Arrive Home in Missouri Hotel stays in route
Cost: $2,000 (paid in 4 installments of $500)
Installments due: December 3, 2018, January 14, February 15, April 15
Price includes all lodging, meals, transportation, all entry prices to tour sights and meals while traveling.
Only expense not included is cost of souvenirs.
Cancellations will be accepted until January 1st with a 50% refund of application fee. If the trip is cancelled because of the lack of interest, the planning committee will reimburse all registration moneys paid. After January 1st, cancellations will only be accepted if a replacement is found. Otherwise, registered youth will still need to pay for the whole trip.
Registration: Forms are available at or contact your 4-H Specialist
Contact: Patty Fisher, CES 4-H Youth Specialist, fisherp@missouri.edu or 573-324-5464
Sarah Morefield, Field Specialist in 4-H Youth, morefieldsa@missouri.edu or 816-407-3490
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