2020-2021 San Mateo/San Francisco Counties Request for 4-H Program Fee Waiver/Reduction

Request for 4-H Program Fee Waiver/Reduction for Youth Members Only

Provisions will be made by the 4-H unit (e.g., club) or volunteer management organization (e.g., council) to cover program fees for eligible youth who are unable to pay them. The parent/guardian of an eligible youth for which a program fee waiver or reduction is requested must complete and submit this form. If you have more than one child, please submit a form for each child.

If you have any questions, please contact Zeva Cho, 4-H Program Coordinator, zfcho@ucanr.edu.

✻ = Required

Youth Member Information

Youth First Name: ✻

Youth Last Name: ✻

4-H Unit: ✻

I am requesting a
(Note: this waiver/reduction covers the state program enrollment fee of $58 or a portion; county fees will be 100% waived but you will need to check with your 4-H Club if there are additional fees) ✻

waiver of the state program fee in full. reduction of the state program fee (indicate amount in the next question).

If you are requesting a reduction of the program fee, please indicate the percentage of the fee reduction (i.e., 20%, 50%, etc) or amount.

Eligibility

UC reserves the right to verify the the information below by further reviewing the household financial status with the parent/guardian.

To determine eligibility for a waiver or reduction of the program fee, please indicate if:

Monthly household cash income is at or below 185% of the Federal Poverty guidelines. If your child is eligible for/enrolled in free or reduced price school breakfast or lunch you meet this criteria. If yes, you can apply for a reduction or waiver of your 4-H program fees. (Reference: http://www.fns.usda.gov/cnd/governance/notices/iegs/iegs.htm)

If your answer is NO, please contact your local club for further assistance. ✻

Yes No

Acknowledgment and Comments

Please enter Parent/Guardian first and last name to acknowledge electronically the statement, "I confirm the information in this application are TRUE, CORRECT, and COMPLETE." ✻

Parent/Guardian Phone #: ✻

Parent/Guardian Email: ✻

Comments or any additional information you would like to share.

ANR NONDISCRIMINATION AND AFFIRMATIVE ACTION POLICY STATEMENT FOR UNIVERSITY OF CALIFORNIA
May, 2015

It is the policy of the University of California (UC) and the UC Division of Agriculture & Natural Resources not to engage in discrimination against or harassment of any person in any of its programs or activities (Complete nondiscrimination policys statement can be found at http://ucanr.edu/sites/anrstaff/files/215244.pdf). Inquiries regarding ANR’s nondiscrimination policies may be directed to UCANR, Affirmative Action Compliance & Title IX Officer, University of California, Agriculture and Natural Resources, 2801 Second Street, Davis, CA 95618, (530) 750-1343.

2020-2021 San Mateo/San Francisco Counties Request for 4-H Program Fee Waiver/Reduction

Request for 4-H Program Fee Waiver/Reduction for Youth Members Only

Youth Member Information

Eligibility

Acknowledgment and Comments

ANR NONDISCRIMINATION AND AFFIRMATIVE ACTION POLICY STATEMENT FOR UNIVERSITY OF CALIFORNIAMay, 2015

ANR NONDISCRIMINATION AND AFFIRMATIVE ACTION POLICY STATEMENT FOR UNIVERSITY OF CALIFORNIA
May, 2015