Officer Contact Page

Please complete this brief form.

Name*
Enter your preferred name as you want it to appear on letters, websites, agendas, etc.
First Last
County*
Council Office*
Select your elected office.
Address*
Street Address City ZIP / Postal Code
Primary Phone*
Enter your personal cell phone #. This is the number that will be used to send text messages and contact you directly.
Secondary Phone*
Enter an alternate number. In case we cannot reach you directly. This could be a parent's number.
Text Messaging*
Do you have the ability to send/receive text messages, AND you are willing to send/receive them in your role as an officer (standard text messaging charges may apply)?
- Yes
- No
Primary Email*
Enter your preferred email address. Some information cannot be sent via text.
Secondary Email*
Enter another email that we can send information to. While you are responsible for managing your own, an alternate email address may help ensure you receive all emailed correspondence. This may be a parent's email address.
Shirt Information
We currently do not have the "style" of shirt selected but this will give us an idea of what kind of shirt to order. Final sizes will be confirmed later. Base your selection as if the style was a polo or button-down short sleeve shirt.
Shirt Size*

District 12 4-H Youth