ISU Extension, Madison County 4-H

Application for Bronze, Silver, and Gold Club

Participation Award (4th-12th grade Community Clubs)

Clubs are eligible to apply every year for any level of this award. This award is open to all community 4-H clubs and

special interest clubs for youth grades 4-12. Please be sure all club activities are properly documented in your club’s

secretary minutes.

Application deadline: September 22, 2017 by 4:30 p.m. to Madison Co. Extension office. (No late entries will be accepted)

Club Name______________________________________________________________________________

Club Leaders_____________________________________________________________________________

Bronze Level

____ Adult and Youth have attended at least 25% of 4-H and Youth Committee meetings.

____ The club has participated in 1 community service activity.

Activity:_________________________________________________________________________

____ Communications: At least 50% of club members grades 4-12 gave a presentation at a 4-H meeting or 4-H function during the 4-H Club year (September 2016-August 2017). ____ The club has fulfilled an assigned duty at each of the following : Covered Bridge Festival booth, fair 4-H food

stand, Jackson Building monitoring, and fair set up/tear down responsibilities.

Silver Level

____ The club has fulfilled all Bronze Level requirements (please indicate with check marks above)

____ Adult and Youth have attended at least 50% of 4-H and Youth Committee meetings.

____ The club can meet at least two of the following (please indicate below):

_____ The club has participated in an additional community service activity.

Activity:___________________________________________________________________________

_____ At least one member of the club has attended a regional, state or national 4-H activity.

(4-H Camp, Animal Science Round-Up, State 4-H Conference, Citizenship Washington Focus, etc.)

_____ The club has participated in 4-H Extravaganza.

Gold Level

____The club has fulfilled all Silver Level requirements. (please indicate with check marks on front page)

____Adult and Youth attend at least 75% of 4-H and Youth Committee meetings.

____The club has met at least three of the following (please indicate):

_____ Club members have served on a 4-H and Youth Committee subcommittee.

_____ The club has contributed to 4-Hers for 4-H.

_____ At least three members of the club have attended a regional, state or national 4-H activity (4-H Camp,

Animal Science Round-Up, State 4-H Conference, Citizenship Washington Focus, etc.). Please list youth

name & activity.

1.) _______________________________________

2.) ________________________________________

3.) ________________________________________

_____ Club leaders, members or families have nominated a potential recipient of a community/adult

recognition award

_____ The club has coordinated a county wide 4-H related event.

Date of Event: _______________________________

Description of Event: ____________________________________________________

_____________________________________________________________________

Club President’s Signature _______________________________________________________________

Club Leader’s Signature _________________________________________________________________

Revised 2/17/2016

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and

activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual

orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Many materials

can be made available in alternative formats for ADA clients. To file a complaint of discrimination, write

USDA, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Wash-