4-H History Round-Up Form | Camp Pioneer

Name (maiden name, if applicable)*

First Last

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone for contact*

Email address*

How affiliated with 4-H:*

Other:*

Years Active in 4-H:*

Name of your 4-H Club:*

Where club met:*

Name of 4-H Club Leader/s:

County Extension Agent/s Names:

Where did you attend 4-H Camp?*

Other – please list locations:*

Do you have 4-H pictures or memorabilia that could be scanned or donated?

Would you be willing to be interviewed?*

Suggestions for people to interview for 4-H History: (please list contact information, if known)