1. education
2. graduate school
3. college

Registration Form
June 15 - June 18, 2015
To Register: Complete this form and submit it to your Unit Extension Office.
Registrations must be submitted by 5 p.m. April 24, 2015.
Required fields are marked by an asterisk (*)
*Participant Type:  4-H youth delegate 
4-H adult volunteer

*Are you a first-time VA 4-H Congress participant?  Yes
*Unit: _Fairfax_____________
Are you a 4-H All Star:
4-H faculty/staff

No
*District: __Northern_________

No

To be Tapped

Yes
Unit Where Tapped ________________
Year Tapped _____________________
Participant Identification:
* Last Name:
* First Name:
* Mailing Address:
* City:
* State:
* Zip
Home Phone Number:
Home E-mail Address:
Youth Cell Phone:
Is it ok to send you Text Alerts during the week if needed
 Yes  No
Age:
* Birthdate (mm/dd/yy):
* Gender:
Race:
Ethnicity:  Hispanic/Latino  Not Hispanic/Latino
 Male  Female
 White  Hispanic/Latino  Black  American Indian/Alaskan Native  Asian
 Native Hawaiian/Pacific Islander Multicultural Prefer not to Answer
Parent/Guardian Identification:
Parent/Guardian's Name:
Parent/Guardian's Work Phone:
Second Parent/Guardian's Name:
Second Parent/Guardian's Work Phone:
Fairfax County 4-H Congress Youth Registration Form - Page 1 of 4
For All 4-H Members:
Roommate preference:
* Name of Adult Chaperone:
Samantha Nagurny
Competition Workshop - June 16: Tuesday Morning
Many youth participate in competitions while at Congress. However, many simply do not know what competition
is all about. To encourage more youth to participate in competition at Congress, competitions workshops will be
offered this year during regular competition times. Delegates should rank competition areas they would like to
learn more about. Rank your workshop preference (with 1 being your top choice and 5 being your last choice).
There will be no changes upon arrival at Congress. Youth that are registering for competitions or national
congress interviews should not selection a competition workshop; youth will attend service learning during
remaining time. Youth that are registering for the shooting education competition should note that they will be
off campus all day long and will not be able to participate in the GSS workshops in the afternoon.
Rank
Competition Workshop
COMPETITOR – DO NOT SIGN ME UP FOR WORKSHOP
NATIONAL CONGRESS APPLICANT – DO NOT SIGN ME UP FOR WORKSHOP
Animal Science: Learning to do the Virginia Youth Cattle Working Contest
Citizenship: Lifesmarts: A Consumer Competition for Teens
Communication and Expressive Arts: Public Speaking and Presentations
Communication and Expressive Arts: Extemporaneous Speaking
Communication and Expressive Arts: Fashion Revue
Healthy Living: Food Challenge
ES/OE: 2015 Hokie BUGFEST 4-H Insect Collection Contest
ES/OE: WHEP
STEM: Electric Challenge
Leadership: National 4-H Congress, International Experience, All-Star Applications
Service Learning: Project Linus Blanketeer
*Service Learning (Project Linus Blanketeer): I plan to bring at least 2.25 yards of fleece to donate to the service
project this year.
 Yes 
No
For 4-H Competition Participants Only (Full Time and One Day Delegates):
* Competitive Event Name (to
ensure proper placement):
List Special Equipment/Space if
Needed:
*List of competitions found in the general information packet
Fairfax County 4-H Congress Youth Registration Form - Page 2 of 4
Great Summer Showcase – June 16: Tuesday Afternoon
Great Summer Showcase is offering many new and exciting workshops this year. They are offered on a first to
register, first to participate basis. Rank your workshop preferences (with 1 being your top choice and 5 being
last choice). Those who do not rank their choices of tracks and workshops will be placed in open workshops.
There will be no changes in workshop assignments upon arrival at Congress.
Rank
GSS Workshop
Animal Science: Discovering the Science of Dairy Science
Animal Science: Alpacas 101
Animal Science: So You Want to be a Large Animal Vet
Animal Science: So What’s It Like to Be A USDA Veterinarian?
Communication and Expressive Arts: Fashion Merchandising
Citizenship: Ouch! That Stereotype Hurts!
Healthy Living: Teen Cuisine
Healthy Living: Smoothie Wars-Will Yours Be the Best
Healthy Living: Salad Factory-One of a Kind Flavorful Salads
Healthy Living: Water Resistance Training
ES/OE: Exploring Horticulture
ES/OE: Entomology
ES/OE: Come Swim with the Fishes
STEM: DNA Extraction and Virginia Bioinformatics
STEM: Solar Power
STEM: National Weather Station Tour and SKYWARN Training
STEM: Go Pro Movie
STEM Drones and Other Unmanned Aerial Vehicles
Leadership: Making A Good First Impression
College Fair Workshop – June 17: Wednesday Morning
The college fair will change format this year. Instead of visiting booths to meet representatives, delegates will
choose a college on campus they would like to learn more about and take an in-depth tour. On each tour, youth
will have the opportunity to engage, interact, and learn more about the college specifically. Delegates should rank
the colleges they would like to learn more about. Rank your workshop preference (with 1 being your top choice
and 5 being your last choice).
Rank
College Fair Workshop
College of Science
Pamplin College of Business
College of Natural Resources and Environment
College of Agriculture and Life Sciences
Edward Via College of Osteopathic Medicine
College of Engineering
College of Veterinary Science
College of Liberal Arts and Human Sciences
College of Architecture and Urban Studies
Virginia State University-College of Agriculture
Ready, Set, Go! How Community Colleges Can Jumpstart Your College Experience
Backpack to Briefcase-Career Preparation
True Colors Personality Assessment
Fairfax County 4-H Congress Youth Registration Form - Page 3 of 4
For All Congress Participants:
Health/Dietary Restrictions or Other Special Needs (please list):
* T-Shirt Size (Adult Sizes)

Small

Medium


Large
X-Large

XX-Large
Other:________
* Registration Fees:
Registration Fees
Optional Fees:
 Full Fee (Youth or Adult) - $235*
 One Day Fee (Youth or Adult) - $40
 Congress Delegation Photo - $5
 Unit Delegation Photo - $5
 Slideshow DVD - $5
*Transportation is included
* Payment
Method of Payment:
Amount:
Can pay via check or credit. See notes below
Check:
Make check out to “Treasurer of Virginia Tech”
Credit:
Pay at the following link: http://tinyurl.com/FairfaxCreditPayment
REGISTRATION CHECKSHEET
Registration Form:
Code of Conduct:

Rankings for:
Attached
4HOnline


Attached
4HOnline
Health History Form:


Payment:

Competition Workshop:

Great Summer Showcase:

College Fair Workshop:

FOR OFFICE USE ONLY:
Date Received
Application Complete?
Payment Received?
Method of Payment
Check/Confirmation #:
Amount:
Fairfax County 4-H Congress Youth Registration Form - Page 4 of 4