_________________________________________________________ 4-H Member’s Name

_________________________________________________________ Parent/Guardian’s Name

_________________________________________________________ Address:

_________________________________________________________ City/ST/Zip:

_________________________________________________________ Daytime Phone

_________________________________________________________ Email

_________________________________________________________ Name of 4-H Club

Name of Animal: __________________________________________________

Date Animal Born: _____________________ Mare Gelding Stallion

Breed: __________________________________________________________

Name of Sire: ____________________________________________________

Name of Dam: ____________________________________________________

Registration No.: __________________________ Un-Registered (Grade):

Date Animal Acquired for a 4-H Project? _______________________________

________________________________________________________________ Signature of Member Date

________________________________________________________________ Signature of Parent/Guardian Date

________________________________________________________________ Signature of 4-H Leader Date

________________________________________________________________ Signature of Extension Youth Educator/Assigned Representative Date

4-H Horse Certificate MEMBER INFORMATION

ANIMAL PROJECT INFORMATION

SIGNATURES

Front View

Right Side View

Left Side View

Rear View

How to Fill Out and Use This Certificate

This certificate is to be submitted annually, filled out with proper signatures. If the same animal

remains a project animal, you will need to submit a new certificate to the County Extension office by

April 1st of each year to meet filing requirements.

4-H Member

All 4-H project horses need to have a completed certificate on file with the county. This certificate is

valuable. Keep it in a safe place. It is a recognition of your project animal. You may be asked to present

it at 4-H fairs to identify your animal. At the end of the year, keep it in your record book as a

permanent record. If you own your 4-H animal and it is registered, you should register it in your name.

Fill out all items on the form correctly, including necessary signatures. To insert your horse photos, you

will need to resize them to fit in the coordinating box OR attach a single page with all 4 photos. Make

3 color copies of the completed certificate and hand them into your 4-H leader. Save a copy for

yourself in your computer documents, print a copy or save on a USB/flash drive for your records.

4-H Leader

Show 4-H members how to fill out the certificate and explain the importance of animal identification.

Have members return completed forms for you to sign and send 2 copies to the County Extension

Office. The horse must be under the member’s care and management for at least 90 days prior to an

exhibit activity.

Extension Youth Educator or Extension Staff

Sign and date each certificate. Return the original copy to the 4-H leader. Keep second copy for

county file.

Who Retains Copies?

4-H Member

Club Leader

Extension Office ─ (will make a copy for the fair superintendent)

Fair Superintendent

WSU Extension programs and employment are available to all without discrimination. Evidence of noncompliance may be reported through

your local WSU Extension office.

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