Page 2 of  5
Name of Applicant:  ______________________________
Parent/Guardian Information - (continued)
 
Father's Name: Occupation: 
Work Address:  
City/State/Zip:  Daytime Phone:  (      ) 

Name(s) and age(s) of sisters: 

   
   
   
Name(s) and age(s) of brothers: 
   
   
   
Health Insurance Information
Do you have any allergies, dietary restrictions or any other health problems? (circle one):    No    Yes
If yes, please explain:
 

Name of Family Health Insurance Carrier:____________________________________________________
I.D. #: ____________________        Group #:  ____________________

Education
Circle the highest grade/year you will have completed by June 30, 2001:    11th Grade       12th Grade
College Freshman College Sophomore College Junior College Senior Advance Degree

Travel
Do you like to travel? (circle one):       Yes       No
Describe some of  your travel experiences:
 
 
 

Leadership & Related Experiences  (Include major experiences in 4-H, church, school, community, other)
 
Name of Organization
Years of Membership
Leadership/Other Responsibilities

 

 

    

 
Page 1
Page 2
Page 3
Page 4
Page 5

2001 Maryland 4-H International exchange Program Application (revised 11/16/98)
Maryland Cooperative Extension programs are open to all citizens without regard to race, color, sex, disability, religion, age or national origin.