SD 4-H Teens As Teachers
Team Registration
Registration Due: March 23, 2015
4-H Teens As Teachers (TAT) Teams may register as a school/organization/club. Teams consist of 2-8 youth.
Team members must be high school sophomores, juniors, or seniors. Graduated seniors are not eligible. It is
encouraged that ½ of the team consist of current 4-H members. Minimal costs may be incurred by teams to
implement their 4-H TAT program.
Group Information
School/Organization/Club: ___________________________________________________
Adult Mentor/Supervising Teacher: _________________________
Street Address: ___________________________________
City: _____________________ State: ___
Number of Teens Participating: ____
ZIP: ______
Males: ______
Office Phone: _______________________
Emergency Phone: ____________________
Adult email: _________________________
Females: ______
Please list the number of participating teens involved in each of the following:
4-H ____ Afterschool Program Worker ____ FCCLA ____ FFA ____ Student Council ____
Youth Internship ____ Other:
____ Other:
____
Teen Teacher Information
Name: ____________________________________
Name: ____________________________________
Address: __________________________________
Address: __________________________________
Phone: ____________________________________
Phone: ____________________________________
Email _____________________________________
Email _____________________________________
Name: ____________________________________
Name: ____________________________________
Address: __________________________________
Address: __________________________________
Phone: ____________________________________
Phone: ____________________________________
Email _____________________________________
Email _____________________________________
Name: ____________________________________
Name: ____________________________________
Address: __________________________________
Address: __________________________________
Phone: ____________________________________
Phone: ____________________________________
Email _____________________________________
Email _____________________________________
South Dakota State University, South Dakota counties, and U.S. Department of Agriculture cooperating. South Dakota State University is
an Affirmative Action/Equal Opportunity Employer and offers all benefits, services, education, and employment opportunities without
regard for race, color, creed, religion, national origin, ancestry, citizenship, age, gender, sexual orientation, disability, or Vietnam Era
veteran status.
© 2015 South Dakota Board of Regents, South Dakota State University
Page 1
SD 4-H Teens Teachers Team Registration
Name: ____________________________________
Name: ____________________________________
Address: __________________________________
Address: __________________________________
Phone: ____________________________________
Phone: ____________________________________
Email _____________________________________
Email _____________________________________
Partnering Group Information (This is the group teens plan to teach e.g. school, 4-H club, afterschool program.)
Partnering Group & Contact Name _____________
Number of youth, the teens plan to reach (Refer to flyer to learn which age each content/curriculum is designed for.)
Pre-K_____ K_____ 1st_____
2nd_____
3rd____
Number of adults (Teach SD curriculum only) _____
4th_____
5th_____
6th_____
Individual Teaching Team Information (Teen teachers often teach in groups of two.)
Teen Teacher Names
HS Grade
Teen Teacher Names
1.
1.
2.
2.
Grade/Age will be teaching
Grade/Age will be teaching
Partner Group Teacher/Adult
Partner Group Teacher/Adult
Email
Email
Teen Teacher Names
HS Grade
Teen Teacher Names
1.
1.
2.
2.
Grade/Age will be teaching
Grade/Age will be teaching
Partner Group Teacher/Adult
Partner Group Teacher/Adult
Email
Email
Teen Teacher Names
HS Grade
Teen Teacher Names
1.
1.
2.
2.
Grade/Age will be teaching
Grade/Age will be teaching
Partner Group Teacher/Adult
Partner Group Teacher/Adult
Email
Email
HS Grade
HS Grade
HS Grade
South Dakota State University, South Dakota counties, and U.S. Department of Agriculture cooperating. South Dakota State University is
an Affirmative Action/Equal Opportunity Employer and offers all benefits, services, education, and employment opportunities without
regard for race, color, creed, religion, national origin, ancestry, citizenship, age, gender, sexual orientation, disability, or Vietnam Era
veteran status.
© 2015 South Dakota Board of Regents, South Dakota State University
Page 2
SD 4-H Teens Teachers Team Registration
Select which Teens As Teachers content area your team would like to participate in (see brochure for descriptions):
____ Option 1: Character Education
____ Option 2: Science, Technology, Engineering & Math
____ Option 3: Nutrition and Physical Activity
____ Option 4: TeachSD
Rank preferred training dates (1 = most favorable):
April 7_____ April 8_____
April 9_____ May 2_____ May 9____
Written Program Plans
Written collectively by your Teens As Teachers Team. Describe in 300 words what need(s) this program will
help address in your community and how your group is prepared to carry out the Teens As Teachers Program.
Include the following as applicable: administrative support, adult mentor support, partnering teacher/adult
support, demographics, community involvement and partnership possibilities. Also, share how your team
members will be able to adjust schedules to accommodate the hours dedicated to this program.
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Submit your application via e-mail or fax by March 23 to:
SDSU Extension Pierre Regional Center
Aletha Scott, Senior Secretary [email protected]
Fax: 605-773-8121
South Dakota State University, South Dakota counties, and U.S. Department of Agriculture cooperating. South Dakota State University is
an Affirmative Action/Equal Opportunity Employer and offers all benefits, services, education, and employment opportunities without
regard for race, color, creed, religion, national origin, ancestry, citizenship, age, gender, sexual orientation, disability, or Vietnam Era
veteran status.
© 2015 South Dakota Board of Regents, South Dakota State University
Page 3