2024-2025 4-H Enrollment FEE WAIVER or REDUCTION Form

Provisions will be made by the 4-H club/unit or county council (VMO) to cover program fees for eligible youth who are unable to pay them. The parent/guardian of an eligible youth for which a program fee waiver or reduction is requested to complete this form.

While fees are waived for your family, they are still paid to the State Office by the 4-H cllub/unit or county council and covered by local fundraising efforts by 4-H families within the county.

Fill in the information below for a full or partial waiver of program fees.

** Payment for the reduced 4-H enrollment fees needs to be mailed or dropped off at the Nevada County 4-H office:

UCCE Nevada County 4-H Office - Grass Valley Veterans Building
255 S Auburn St., Grass Valley, CA 95945
Open from 8:00 A/m/ to 4:30 p.m. Tuesday and Thursday

Mailing address: P.O. Box 2851, Grass Valley, CA 95945

Make sure you complete your 4-H Enrollment before submitting this fee waiver or a partial fee payment.

Please submit ONE form per youth member.

✻ = Required

Parent /Guardian /payor Information (Please do not use Auto-Fill)

Email Address: ✻

Last Name: ✻

First Name: ✻

Daytime Phone Number: ✻

4-H Membership Information
** SUBMIT A SEPARATE WAIVER REWQUEST FOR EACH MEMBER **

4-H COUNTY: ✻

4-H CLUB: ✻

Member's First Name: ✻

Member's Last Name: ✻

FULL PROGRAM FEE WAIVER
of the $67.00 per Member fee

I certifiy that I am the parent and/or legal guardian of the youth on this form. By checking "Yes" in this box on this form, I attest that I am providing information that is true and correct. ✻

Yes No

The parent/guardian of an eligible youth for which a program fee waiver or reduction is requested *attests that the child included in this request is eligible.

To determine eligibility for a full waiver or reduction of the program fee, please indicate if:

Annual household cash income is at or below $50,560.

See Reference:
https://www.fns.usda.gov/cn/income-eligibility-guidelines, 2023-2024 Federal Poverty guidelines.

UC reserves the right to verify the above information by further reviewing the household financial status with the parent/guardian.

Need-based fee waivers are offered to youth only.

✻

Yes No

PARTIAL PROGRAM FEE WAIVER
of the $67.00 per Member fee

Are you requesting a reduction of the program fee? ✻

Yes No

If you are requesting a reduction of the enrollment fee for this youth, enter partial payment amount you will pay by cash or check at the Nevada County 4-H Office here.

Thank you for filling out the information.
To submit a payment, please either mail or drop off payment at the Nevada County 4-H office.

Our office is open Tuesday & Thursday from 8:00 a.m. to 4:30 p.m.
Grass Valley veteran's Building, 255 South Auburn St. Suite 1, Grass Valley, CA 95945

Mailing address: P.O. Box 2851, Grass Valley, CA 95945

2024-2025 4-H Enrollment FEE WAIVER or REDUCTION Form - Nevada