Registrations | Illinois Extension

Join us as we celebrate the hard work, growth, and accomplishments of our 4-H members!

November 7 | 2:00 pm to 4:00 pm | Monticello Community Building | 201 N. State St. | Monticello, IL 61856

The purpose of our awards program is to provide an avenue for youth recognition and to provide 4-H members with an opportunity to showcase their growth, learning, and reflection surrounding their 4-H participation in the past year.

Come out and enjoy an afternoon of celebration with your 4-H friends and family, and enjoy:

Register by November 1

**Our event space has a 2 ft. stage for the award ceremony. 4-H members will use the stage to accept their awards.

**To request a reasonable accommodation or fee waiver, please contact Anne Reinbold.
**NOTE: You do NOT need to create an Extension User Account to register. Please complete the contact information below.**

Contact Information

First Name

Last Name

Street Address

Street Address 2

City

State

ZIP

Daytime Phone

Evening Phone

E-mail Address

How many participants will be attending in your group?

Please list the names and ages of all participants attending in your group. *ex.) John Smith - 5 years old

Please list any food allergies, sensitivities, or health conditions your child may have that we should be aware of. *if none please input N/A

Do you need any support or accommodations to participate in this program? *early requests are encouraged to allow sufficient time for meeting access needs. | If none please input N/A

Photo/Talent Release: I, the undersigned, do hereby consent to the use by The Board of Trustees of the University of Illinois (“University”) of my image, voice, or both described below, in (1) the video, photograph, or audio recording described below; and (2) any video, photograph, or audio recording reproduced either in whole or in part from the video, photograph or audio recording described below: regardless of whether these materials are used for fundraising, advertising, publicity, or any other purpose on behalf of either the University or its Foundation. I warrant that I have the full right and authority to grant this consent. In addition, I waive all claims to compensation or damages based on the use of my image or voice, or both, by either the University or the Foundation. I also waive any right to inspect or approve the finished photograph or video or audio recording. I understand that this consent is perpetual, that I may not revoke it, and that it is binding on me, my heirs and assigns. I warrant that I am at least 18 years of age and that I am competent in my own name insofar as this consent is concerned, or that I am the parent or legal guardian authorized to sign on behalf of a person under age 18. I further attest that I have read this consent form and fully understand its contents. Do you consent to this form?

Yes, I consent.

No, I do not consent.

First and Last Name/Signature of Talent (or parent/legal guardian if under 18): *By entering your name you consent to the release of all video/photo/audio recorded during this program. | If you do not consent, please input N/A.

Civil Rights Compliance - Participant Info

As part of our commitment to providing equal opportunities in our programming, University of Illinois Extension is required to collect and report overall statistics about the race, ethnicity, and gender of program participants. Your responses are voluntary and appreciated.

Gender

Ethnicity

Race

DeWitt, Macon, and Piatt County 4-H Awards Reception

Already have an Extension User Account?

Contact Information

Civil Rights Compliance - Participant Info