Youth Development Program / Workshop Request Form

✻ = Required

Contact Name: ✻

Facility or Site Name ✻

County ✻

Facility/Site Physical Address

Use the location search to find the location

Location Search ✻

Address ✻

Address 2

City ✻

State ✻

Postal Code ✻

Country ✻

Contact Phone Number ✻

Contact Email Address ✻

Please identify how your site would like to participate ✻

4-H SPIN Club 4-H School Enrichment 4-H Afterschool Education Professional Development Direct Delivery Material Use

Please identify which resource(s) you are interested in ✻

Please identify the audience for the program/workshop (select all that apply) ✻

Adult Professionals Adult Volunteers Youth 5 - 8 years old Youth 9 - 11 years old Youth 12 - 14 years old Youth 15 - 19 years old Teens as Teachers

Date of potential workshop/program ✻

Time of potential workshop/program ✻

Number of youth participants for workshop/program ✻

Number of adult participants for workshop/program ✻

Complete the following questions only if a program/workshop is being requested

What are your goals for this program/workshop?

What outcomes do you want met as a result of this program/workshop?

Identify any special needs or circumstances that may impact the delivery of the program/workshop

Does your organization have a facility where the program/workshop can take place? Please describe

For additional information contact:

Russell Hill

4-H Youth Development Advisor

Madera, Mariposa and Merced Counties

rdhill @ucanr.edu

(209)385-7418 - Merced Office