Youth Multimedia Team Electronic Application

Application Information
First Name:
Last Name:
Address:
City:
State:
Zip:
County:
Phone:
Email:
Age (as of January 1):
Years in 4-H:

More Information
I will be able to participate in all virtual meetings and activities as stated on the Multimedia Team Fact Sheet.
Yes	No If no, explain in the space below.

I will be able to locate an environment that contains a computer with high bandwidth Internet connection, as well as a phone line, allowing me to participate in all virtual meetings and activities stated on the Multimedia Team Fact Sheet. (Yes/No) If no, explain.
Yes	No If no, explain in the space below.

Name of UNL Extension Staff who will complete the Nominating Form on your behalf (for youth multimedia members only)

Please print this page for your records.

Nebraska 4-H Youth Multimedia Team
Online Application Form