UGA Cooperative Extension: Georgia 4-H

Jekyll Island 4-H Center:
ES 237 Form

Thank you for returning this completed form to the Lead Staff Member or Program Coordinator. The information is required for the Federal Government.

School:_________________________________________________

County:__________________________________________________

Today’s Date:_________________________________

Total # of Students & Adults Attending Program = ______

Student Numbers

Total number of students:________

White Male:______ Black Male:______ Hispanic Male:_____ Asian Male:______ Multi-cultural Male:______

White Females:______ Black Female:______ Hispanic Females:______ Asian Females:______ Multi-cultural Females:______

Adult Numbers

Total number of adults:________

White Male:_____ Black Male:_____ Hispanic Male:_____ Asian Male_____ Multi-cultural Male:_____

White Female:_____ Black Female:_____ Hispanic Female:_____ Asian Female:_____ Multi-cultural Female:_____