Enroll in Georgia 4-H — Fulton County

Club Name(Required)

School Name(Required)

Grade(Required)

Student Name(Required)

First Last

Preferred Name(Required)

Date of Birth(Required)

Gender(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Secondary Email

Cell Phone(Required)

Home Phone

T-Shirt Size(Required)

Race and Ethnicity (check all that apply) (optional)

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

Are you a member of a military family? (Please select yes if you have a parent or legal guardian who is actively serving in any branch of the military.)

Yes

Select your residence.(Required)

Health concerns or special needs you'd like the extension office to be aware of:

Parent Name(Required)

First Last

Preferred Parent Name

First Last

Email(Required)

Secondary Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

Gender(Required)

Cell Phone(Required)

Home Phone

Work Phone

Relationship to Student(Required)

Second Parent Name

First Last

Preferred Parent Name

First Last

Gender

Secondary Email

Address

Street Address Address Line 2 City State ZIP Code

Cell Phone

Home Phone

Work Phone

Relationship to Student