Registration

Teen Teacher Interest

Thanks for your interest in the 4-H Teen Teacher program! Please share your information below so we can follow up with you with more details.

Already have an Extension User Account?

Optional: This will automatically fill in your contact details for a faster registration.

Contact Information

First Name

Last Name

Street Address

Street Address 2

City

State

ZIP

Daytime Phone

Evening Phone

E-mail Address

Is it okay to text?

Yes

What County do you live in?

How old are you currently?

Other

What grade are you in?

What school do you attend?

Parent/Guardian Name

Parent/Guardian Cell Phone We will only use this information for communication about the Teen Teacher program. We will not provide this information to anyone else.

Parent/Guardian Email We will only use this information for communication about the Teen Teacher program. We will not provide this information to anyone else.

How did you hear about the 4-H Teen Teacher program?

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

Illinois Extension

Registration

101 Mumford Hall (MC-710)

1301 W. Gregory Dr.

Urbana, IL 61801

Phone: 217-333-5900