NAME                                                                                 AGE (as of 1/1/05)                         GENDER ____

ADDRESS                                                                           PHONE__________ 

CITY                                                                                     STATE                  ZIP_______ 

COUNTY                                                                                                                             DISTRICT          West 

PLANNED CAREER                                                                                      SS# ____________________ 

CLUB/GROUP NAME                                                     YRS. IN 4-H             GRADE IN SCHOOL_______

 (* - Requires completion of separate, specialized application form. Ohio  4-H Achievement Record not required for eligibility.)

STATE OPPORTUNITIES: Check your choices.  See State Achievement Record Instructions & Details on Pages 2 & 3.

____ State Junior Fair Board                         ______Natl 4-H Dairy Conference
______Ohio Dairy Goat Conference                   ______OTA Local Govt. Award             ____ International Programs*
______Ohio 4-H Ambassador Program*             ______International Programs*              ______Ohio 4-H Scholarships*

______National 4-H Congress/State Achievement Award:
              ___Beef                                            ___Citizenship & Community Service       ___Clothing & Textiles
              ___Dairy                                          ___Dairy Goat                                        ___Environmental Science
              ___Family Life & Child Dev.              ___Foods & Nutrition                             ___Gardening & Horticulture
              ___Health & Safety                            ___Horse                                                ___Leadership
              ___Mech. & Engineering Sci.              ___Personal Development                         ___Rabbits & Poultry
              ___Sheep                                         ___Shooting Sports                                 ___Swine
              ___ Veterinary Science

COUNTY OPPORTUNITIES: Please rank your interests (1,2, etc.). See County Instructions and Details on page 9 & 10.

______4-H Youth Conference            ______4-H Conservation Camp                     ______Carving New Ideas Workshop*
______4-H Sea Camp*                    ______4-H Leadership Camp                        ______Buckeye Leadership Workshop*
______4-H Washington Focus           ______Ohio Forestry Camp*                       ______Food & Fashion Board*
______County Junior Fair Board*      ______County 4-H Scholarships                   
______4-H Boy or Girl of the Year* (submit this form in early July)

                                                     APPROVAL OF THIS RECORD
I personally have prepared this record and certify that it accurately reflects my work:

Date                ,                    Signature of 4-H member: _____________________________________

We have reviewed this record and believe it to be correct:
Date                     ,                    Signature of parent/guardian: ___________________________

Date                     ,                    Signature of 4-H Advisor/Volunteer: _______________________

Date                     ,                    Signature of Extension Agent: _______________________________

* State Junior Fair Board - Is comprised of representatives from several different youth organizations in Ohio including 4-H Youth Development.  State Junior Fair Board members help strengthen and coordinate State Fair activities in a fast-paced, action-packed month at the Ohio State Fair.  Junior Fair Board members are expected to attend meetings and stay at the fair for the entire 12 days.  The Ohio State Fair will be held in Columbus, Ohio and is  scheduled for August 3-14, 2005.

* National 4-H Dairy Conference - This national event provides delegates with an opportunity to learn more about the dairy industry and observe new dairy industry developments.  The conference is tentatively scheduled to be held at the University of Wisconsin (located in Madison, Wisconsin) from October 2-5, 2005..

* Ohio Dairy Goat Conference - This conference provides delegates with the opportunity to learn more about the dairy goat industry and observe new dairy goat industry practices. The conference is tentatively scheduled to be held at the Ohio State University in Columbus, Ohio sometime in September/October, 2005.

* OTA Local Government Award - Two $1,500 awards are available to any 4-H high school senior who has completed  a local government-type activity that has had significant impact on the applicant's community, township or county.

* State Achievement Awards - These 19 awards recognize a 4-H member's achievement in a specific area.  Areas include: Beef, Citizenship & Community Service, Clothing & Textiles, Dairy, Dairy Goat, Environmental Sciences, Family Life & Child Development, Foods & Nutrition, Gardening & Horticulture, Health & Safety, Horse, Leadership, Mechanical & Engineering Sciences, Personal Development, Rabbits & Poultry, Sheep, Shooting Sports, Swine, and Veterinary Science.  Each achievement award winner will receive a trip to the National 4-H Congress which is scheduled to be held in Atlanta, Georgia from November 25 - 29, 2005.

*^ Ohio 4-H Scholarships - There are 24 state 4-H scholarships available in 2005 and each has its own description and its own  list of eligibility requirements.  Completion of an Ohio 4-H Achievement Record is not necessary to be eligible for this award/opportunity.  Instead, a separate, specialized application form is required to be completed.  You should indicate your interest in this award/opportunity on page 1 of this form and an Ohio 4-H Scholarship Application form can  be obtained at the Extension Office.

*^ Ohio 4-H Ambassador - Each year, delegates are selected from each county to serve a one year active term as a State 4-H Ambassador.  Ambassadors are selected based on their accomplishments in leadership, public speaking, and community service and are required to attend comprehensive training, and represent Ohio's 4-H youth at various state and local events.  Completion of an Ohio 4-H Achievement Record is not necessary to be eligible for this award/opportunity.  Instead, a separate, specialized application form is required to be completed.  You should indicate your interest in this award/opportunity on page 1 of this form and an Ohio 4-H Ambassador application form can then be obtained at the Extension Office.

^ International Programs - These programs allow 4-H'ers and alumni ages 14-30 to serve as a host to a youth from another country or to travel abroad as a 4-H representative to more than 30 countries around the world.  Some scholarships are available for travel.  Completion of an Ohio 4-H Achievement Record is not necessary to be eligible for these awards/opportunities.  Instead, a separate, specialized application form is required to be completed.  You should indicate your interest in this award/opportunity on page 1 of this form and an International Programs packet can then be obtained at the Extension Office.
See COUNTY ACHIEVEMENT OPPORTUNITIES on page H-9.

To be eligible for all state opportunities listed on the cover sheet of this form (not marked with a * symbol), members need to complete this “Ohio 4-H Achievement Record” and meet all of the criteria listed below.  The “Ohio 4-H Achievement Record” is comprehensive in nature and may take some time to complete.  Work on it should be started as soon as possible.  The completed form is due at your county OSU Extension office by the deadline listed on the cover sheet of this form.

 1) Applicants must at reached their 14th birthday, but did not reach their 19th birthday, sometime before January 1, 2005.   (Note: 4-H membership ends December 31 of the year in which an individual attains the age of 19).

2) Applicants must be currently enrolled as an Ohio 4-H member.

3) Limit type/print to no more than 15 characters per inch (including 4-H personal story).  (Note: 10 points will be deducted if this requirement is not followed.)

4) No additional pages may be added to any section (A through G) of the “Ohio 4-H Achievement Record.”  (Note: 10 points will be deducted if this requirement is not followed.)

5) Your “Ohio 4-H Achievement Record” should be stapled in the upper left hand corner.  Do not use tabbed dividers, coversheets, or any type of folder/binder.  (Note: 2 points will be deducted if this requirement is not followed.)
 
 

^   When applying for STATE (OHIO) 4-H ACHIEVEMENT OPPORTUNITIES, please submit the following items:

•   Your completed “Ohio 4-H Achievement Record” (each page single-sided).  Stapled in the upper left hand corner.   No tabbed      dividers, coversheets, or any type of folder/binder. (90 points)
•   A Personal 4-H Story: Share how 4-H contributed to your personal development, leadership skills, and/or career plans. Limited to two pages (single-sided, double-spaced). (5 points)
•   Activity and project photos sheet: Limited to one 8 ½ x 11 inch page, one side only. (5 points)

* In order to apply for STATE (OHIO) 4-H SCHOLARSHIPS, it is not necessary to complete an “Ohio 4-H Achievement Record.”  Instead, it is necessary to complete of an “Ohio 4-H Scholarship Application”.  Please ask your county OSU Extension office for the appropriate form if you are interested in applying for a state 4-H scholarship.

* In order to apply for STATE 4-H AMBASSADOR, and/or INTERNATIONAL PROGRAMS, it is not necessary to complete an “Ohio 4-H Achievement Record” because each of these items requires the completion of a different, specialized form.  Please ask your county OSU Extension office for the appropriate forms if you are interested in applying for one of these awards/opportunities.
 
                                                                                                     H-3

DO NOT ADD ADDITIONAL PAGES

A. 4-H PROJECT WORK (20 points): List by major projects and/or program areas. Use numbers when appropriate to show size, extent, growth, number of items, savings, etc. over time.
Year   Project name       Things made, produced, learned, etc.
2004   Woodworking     Made a bookshelf for my room; worked 57 hrs, $72; saved $100; learned to use a sander.

B. 4-H PARTICIPATION (20 points): List 4-H activities, field trips, tours, workshops, camps, judging events, contests, exhibits.
Year   Event          What I did; where event took place; including demonstrations and talks given.
2004   Field Trip   Went with 4-H group to the Ohio Dairy Research Center; gave two talks to 4-H dairy clubs.

Year    Honor        For what accomplishment
2004    1st Place   Trophy State Fair Model Rocketry Evaluation

D. 4-H COMMUNITY SERVICE/CITIZENSHIP (10 points): Activities performed through 4-H to benefit community.
Year     Name of Activity      What I did, accomplished, or learned
2004     “Adopt-a-Road”       Picked up trash two times along a 2 mile stretch of road.

E. 4-H LEADERSHIP: EDUCATIONAL/PROMOTIONAL (15 points): Activities performed to benefit and strengthen 4-H.
Year    What I did, organized, taught or accomplished
2004    Taught 10 members how to properly construct a birdhouse at our club meeting.

F. 4-H LEADERSHIP: OFFICE/COMMITTEE (10 points):
Year    Office/Committee (elected/appointed)         What I did and/or learned
2004   Treasurer, Splashers 4-H Club                       Kept list of dues, wrote checks and gave reports.

G. NON 4-H EXPERIENCES IN SCHOOL, CHURCH AND COMMUNITY (5 points):
Year    List your most meaningful participation in school, church and community organizations.
2004    Directed Senior Class Play including a cast of 30 members.

*   4-H Conservation Camp - A six day camp (July 25 - July 30) held at Camp Ohio, Utica. Primarily designed for youth interested in Environmental Sciences. Participants learn by doing, using Camp Ohio as their laboratory.

*   4-H Leadership Camp - A six day camp (July 25-30) held at Camp Ohio, Utica. This program focuses on helping  youth develop leadership by actually planning, conducting, and evaluating major parts of the camp program.

     Carving New Ideas Workshop - This program  is conducted by Ohio State's Collegiate 4-H Club at Camp Ohio and emphasizes recreational leadership skills and fun activities.

*   Ohio Forestry Camp - This six day camp (June ??-??) is held at FFA Camp Muskingum, Leesville Lake, Carroll  county. The program focuses on tree identification, silviculture, ecology and forest products (2 selected).

^  4-H Camp Counselor - All camps are held at 4-H Camp Clifton.  An Ohio 4-H Achievement   Record does not have to be completed in order to be eligible for this award/opportunity.  A separate, specialized  application form is required to be filled out for this opportunity.  The Counselor application is due by December 17, 2004 to the County Extension  Office.

*   County Junior Fair Board (current H.S. freshmen & older) - Youth selected may serve up to two years.  A separate application  is required and is due in the fall of the year. (number selected varies by year)

*   County 4-H Scholarship (usually H.S. Seniors) -  Request county 4-H scholarship eligibility requirements and application  sheets from your County Agent.  County scholarship applications are required to be turned in with a copy of your "Ohio 4-H Achievement Record".

*   4-H Boy & Girl of the Year  (1 Girl, 1 Boy selected). Application (this Ohio 4-H Achievement Record) is due in July. Must be 17 or older as of January 1st.

 Buckeye Leadership Workshop (16 & older) - Learn recreational leadership skills at this outstanding event held
    March 19-24 at Recreation Unlimited Camp in Delaware, Ohio.  Scholarships may be available for the Workshop.

 4-H Sea Camp - Experience marine biology first-hand at Kelleys Island 4-H Camp on Lake Erie.  This is tentatively  scheduled in July .  Fishing, ecology, marine navigation, snorkeling, SCUBA, sailing and much more.
 
 

See STATE ACHIEVEMENT OPPORTUNITIES on page H-2.

To be eligible for all county opportunities/scholarships listed on the cover sheet of this form (not marked with a * symbol), members need to complete this “Ohio 4-H Achievement Record” and meet all of the criteria listed below.  County selections are based upon program and/or project work, participation in 4-H events, exhibited leadership, community service, 4-H Story, project/activity photos and degree of interest described by applicant.  The “Ohio 4-H Achievement Record” is comprehensive in nature and may take some time to complete.  Work on it should be started as soon as possible.  The completed form is due at your county extension office by the deadline listed on the cover sheet of this form.
 
 

1) Applicants must at reached their 14th birthday, but did not reach their 19th birthday, sometime before January 1, 2005.   (Note: 4-H membership ends December 31 of the year in which an individual attains the age of 19).

2) Applicants must be currently enrolled as an Ohio 4-H member.

3) Limit type/print to no more than 15 characters per inch (including 4-H personal story).  (Note: 10 points will be deducted if this requirement is not followed.)

4) No additional pages may be added to any section (A through G) of the “Ohio 4-H Achievement Record.”  (Note: 10 points will be deducted if this requirement is not followed.)

5) Your “Ohio 4-H Achievement Record” should be stapled in the upper left hand corner.  Do not use tabbed dividers, coversheets, or any type of folder/binder.  (Note: 2 points will be deducted if this requirement is not followed.)
 
 

^  When applying for COUNTY 4-H ACHIEVEMENT OPPORTUNITIES, please submit the following items:

•  Your completed “Ohio 4-H Achievement Record” (each page single-sided).  Stapled in the upper    left hand corner.   No tabbed dividers, coversheets, or any type of folder/binder. (90 points)
•  A Personal 4-H Story: Share how 4-H contributed to your personal development, leadership skills and/or career plans. Limited to two pages (single-sided, double-spaced). (5 points)
•  Activity and project photos sheet: Limited to one 8 ½ x 11 inch page, one side only. (5 points)

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