Annual School Enrollment Form

ANNUAL SCHOOL ENROLLMENT FORM

In accordance with state and federal guidelines, schools must enroll each year to remain active in the 4-H Wildlife Stewards program. The 4-H enrollment year begins October 1st. All schools must enroll by December 31st in order to continue to receive information and support.

Please be sure to fill in required areas (*). Thank you!

GENERAL INFORMATION
Name of School: *
Grades Involved: * (Check all that apply)			K-2
			3-5
			6-8
			9-12
School Address: *
City: *
Zip Code: *
County: *
Designated Contact Name: *
Phone: *
Email: *
School Website: *
School Residence:
Principal Name:
TEACHER PROFILE
*Indicate the number of participating teachers in each category:

	Caucasian	African American	Hispanic	Asian	Native American
Males
Females

STUDENT PROFILE

*The following section on classroom information must be filled out completely. This information is needed for statistical reporting in compliance with Federal Funding requirements. Racial data is required by Affirmative Action Policy. All information is kept confidential.

GRADE

Classroom
Composition

Caucasian

(F)

(M)

African
American

(F)

(M)

Hispanic

(F)

(M)

American/
Alaskan Native

(F)

(M)

Asian Pacific Islander

(F)

(M)

Totals

HABITAT EDUCATION
*Site features completed or in progress. Please check all that apply:
	Bird Garden
	Butterfly Garden
	Vegetable Garden
	Historical Garden
	Woodlands
	Wetlands
	Native American Garden
	Garden Pond
	Bioswales
	Dry Stream Bed
	Stream Restoration
	School Nursery
	Greenhouse
	Worm Composting
	Nest Boxes
	Amphitheater
	Learning Shelter
	Wheelchair Accessible

PROJECT HIGHLIGHTS
Tell others about your project and what you are learning. Please limit your entry to 250 words. Would you be interested in participating in an on-line exchange with other classrooms? Yes No Share your thoughts: How is your project helping students improve their science skills? Please limit your entry to 250 words or less.
LEVEL OF PARTICIPATION
Indicate the average number of hours per month your average students participate in these hands-on projects:
	1-2 hours
	3-6 hours
	7-15 hours
	more than 15 hours

Number of Participating Volunteer Parents who volunteer with the habitat education site:

FUNDING SOURCES
Estimate the amount of funds you generated this year:

In-kind donations		$
Grants		$
Sales/Fundraisers		$
Cash Donations		$
TOTAL		$

PARTNERS
Please list key organization and group partners who assisted with this project such as community clubs, neighborhood associations, community agencies, garden shops, etc.
Square Feet of Wildlife Habitat Created and/or Maintained This year