<%@LANGUAGE="JAVASCRIPT" CODEPAGE="1252"%> University of Georgia Jekyll Island 4-H Center

ES 237 Form

Thank you for returning this completed form to the Lead Staff Member or Program Coordinator. The information is required for the Federal Government.

School:_________________________________________________

County:__________________________________________________

Today’s Date:_________________________________

Total # of Students & Adults Attending Program = ______

Student Numbers

Total number of students:________

White Male:______ Black Male:______Hispanic Male:_____Asian Male:______

Multi-cultural Male:______

White Females:______ Black Female:______Hispanic Females:______

Asian Females:______Multi-cultural Females:______

Adult Numbers

Total number of adults:________

White Male:_____ Black Male:_____Hispanic Male:_____Asian Male_____

Multi-cultural Male:_____

White Female:_____ Black Female:_____Hispanic Female:_____

Asian Female:_____Multi-cultural Female:_____

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The University of Georgia and Ft. Valley State University, the U.S. Department of Agriculture and counties of the state cooperating. The Cooperative Extension Service offers educational programs, assistance and materials to all people without regard to race, color, national origin, age, sex or disability. An equal opportunity/affirmative action organization committed to a diverse work force.