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| Name of Applicant: _______________________________ |
General Information
List other information that would be helpful in our placement with
a program (include medical considerations or special interests).
How did you learn about the 4-H International Exchange Program with
the United Kingdom?
References
Applicants are required to list at least one MCE staff member; the
others may be anyone other than relatives)
| Name: |
Daytime Phone: (
) |
| Address: |
City/State/Zip: |
| Name: |
Daytime Phone : ( ) |
| Address: |
City/State/Zip: |
| Name: |
Daytime Phone: ( ) |
| Address: |
City/State/Zip: |
| FEE: The cost of the United Kingdom Program is $1,000
per participant. Applicants selected to participate will be responsible
for $500.00 of this fee. The county/city extension office in which
the applicant is enrolled will be responsible for $250.00 and the Maryland
State 4-H IFYE Program for $250.00.
Fee is due March 1, 2001. Checks should be made out to:
The Maryland 4-H Foundation.
|
I CERTIFY that all of the information on this application is
true and complete to the best of my knowledge. I understand the purposes
and objectives of 4-H international exchange programs and agree
to participate with the framework of the program for the United Kingdom
Ambassador Exchange Program with Maryland. I agree to prepare
a report on a topic of my choice by November 1, 2001. I also agree
to give a verbal report to at least 3 groups such as 4-H clubs, farm groups,
other youth groups or classes within 1 year after I return.
Applicant's Signature
Parent/Guardian's Signature (if applicant is under 18 years of age at
time of application)
County/City 4-H Extension Educator's Approval Signature
2001 Maryland 4-H International Exchange
Program Application (Revised 10/23/00)
Maryland Cooperative Extension programs are open
to all citizens without regard to race, color, sex, disability, religion,
age or national origin.