EmailMe Form - 2012-2013 4-H Eligibility

Name of 4-H Member *

First Last

Parent Phone # *

### - ### - ####

Primary 4-H Club *

In accordance with 4-H policy and TEA Academic Eligiblity Guidelines, I respectfully request: *

Academic Eligibility ONLY (my child will not miss any school class time)

Academic Eligiblity and authorization to receive an excused absence from school for the activities I have indicated below.

You may only choose one!

My Child is in the *

at (Campus Name) *

Please check one: *

Public School

Private School

Home School

Name of 4-H Activity or Event *

Date(s) Participating: *

If this request is for livestock show, indicate what you will be exhibiting. (i.e. market goat, breeding sheep, horse, heifer)

**We (member and parent/s) understand that follow-up details on the member's participation will be provided to schools as required. *

As parent or legal guardian of the aboved mentioned 4-H member I agree that typing my name below serves as my valid signature.

Signature of Parent/Guardian: *

First Last

Date of Request *

MM / DD / YYYY

This information is requested in accordance with the requirements of Senate Bill 1 and in cooperation with the Texas Education Agency and local public school board policies. This form serves as the official school notification of the 4-H member's intent to participate in one or more extra-currcular activities representing 4-H.