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DECLARATION OF ELIGIBILITY FORM PARENT/GUARDIAN /COUNTY EXTENSION AGENT - Complete This Section In accordance with 4-H policy provided by our local Extension office I respectfully request check one Academic eligibility information only Date of Activity s Name of Activity Signature of Parent/Guardian I hereby certify that is a member of 4-H in Brazos County and is scheduled to participate in this activity representing 4-H. He/she will be under the supervision of Texas A M AgriLife Extension faculty and/or our agency s designated volunteer leader. Date County Extension Agent PRINCIPAL - Complete This Section Check one I do certify that the student is academically eligible to participate in the above mentioned extracurricular activity. He/she will be under the supervision of Texas A M AgriLife Extension faculty and/or our agency s designated volunteer leader. Date County Extension Agent PRINCIPAL - Complete This Section Check one I do certify that the student is academically eligible to participate in the above mentioned extracurricular activity. I do not certify the student because he/she is NOT academically eligible to participate in the above mentioned extracurricular activity. An excused absence will be granted* Does not apply. Signed Date Principal or Designee Name of School Instructions on back Educational programs of the Texas A M AgriLife Extension Service are open to all people without regard to race color sex disability religion age or national origin* The Texas A M University System U*S* Department of Agriculture and the County Commissioners Courts of Texas Cooperating. WORK FROM THE TOP DOWN Parents/Guardians fill out the top portion including 1. The academic eligibility information boxes and the Date of the activity the Name of Activity 2. The parent/guardian signature 3. AND the Name of the child Extension office 4. Our office fills in the date and uses a signature stamp for the County Extension Agent signature. The principal of your child s school will fill in the bottom portion including 6. The absence box es 7. The Principal s signature with the name of school and date signed The Extension office will then need a copy for our documentation and the child will keep the original to be presented if needed to the event supervisor or the school* The copy may be sent any of the following ways Mailed to our office at 2619 Highway 21 W* Bryan TX 77803 Scanned and emailed to ejbesser ag. tamu. edu or gjhoyt ag. tamu. edu Faxed to 979-775-3768 Brought in and we will make the copy for you. He/she will be under the supervision of Texas A M AgriLife Extension faculty and/or our agency s designated volunteer leader. Date County Extension Agent PRINCIPAL - Complete This Section Check one I do certify that the student is academically eligible to participate in the above mentioned extracurricular activity. Date County Extension Agent PRINCIPAL - Complete This Section Check one I do certify that the student is academically eligible to participate in the above mentioned extracurricular activity. I do not certify the student because he/she is NOT academically eligible to participate in the above mentioned extracurricular activity. .

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