CITIZENSHIP WASHINGTON FOCUS TRANSMITTAL FORM
June 15 – 25, 2017
Delegates must be 15 by time of trip
Full Payment of $1,540.00 is required along with registration information by 5:00 pm, February 28, 2017
Submit to:
STATE 4-H OFFICE, ATTN: CWF Coordinator, 205 4-H Youth Development, Oklahoma State University, Stillwater, OK 74078-6063
àààààIMPORTANT NOTICEßßßßß
*Submission of the transmittal form is a commitment to make the total payment of $1,540.00 by February 28, 2017. The names listed as delegates on the transmittal form received in the State 4-H Office by February 28, 2017 will be ranked by birth date until 40 spots are filled (with oldest given preference). These 40 will be guaranteed a place on the bus. On the next working day after the deadline if there is space available, the names listed as the first alternate on the form will be ranked by birthdates and added until 40 spots are filled. If there is space available after the 1st alternates, the remaining names will then also be ranked by birth date and added as delegates or placed on the alternate list. In case of cancellations, alternates from the list would be contacted by age.
COUNTY:Name / Address / City, Zip / Birth Date / Gender / Phone / Race* / Email Address / Polo Shirt Size
Delegate
Alternate 1
*Race (Optional): AP= Asian/Pacific Islander, AA= African American, C= Caucasian, H= Hispanic, NA= Native American or Alaskan Native
I hereby verify that this information is correct
Signature of Extension Educator
FOR INDIVIDUALS WITH DISABILITIES WHO REQUIRE AUXILIARY AIDS OR SERVICES FOR PROGRAM PARTICIPATION, PLEASE IDENTIFY THE ACCOMMODATION/SERVICE NEEDED WHEN SUBMITTING THIS FORM. ADVANCE NOTICE IS NECESSARY FOR EFFECTIVE SERVICE PROVISION; IT MAY NOT BE POSSIBLE TO PROVIDE SOME AIDS AND SERVICES WITH LATE NOTICE. REASONABLE EFFORT WILL BE MADE TO ACCOMMODATE INDIVIDUALS WHO REQUEST AUXILIARY AIDS OR SERVICES.