Teton County 4-H Request for Variance Form


Name:__________________________________________________________________  Age:________________________
Mailing Address:_____________________________________________________________________________________
Explain the rule and/or deadline that was not met:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

What is the reason the rule and/or deadline was not met?

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

What action are you requesting to be taken or what variance are you requesting?  Why?

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

________________________________________________________________________________________________________

What consequence would you consider?

___Late fee and/or suggested amount:________________________________________________________________

___Service (to Extension, 4-H community, etc):_________________________________________________________

___Leadership Project:_________________________________________________________________________________

___Other:_______________________________________________________________________________________________

 

Signature:_____________________________________________________Date:____________________________________

 

Parent/Guardian Signature:___________________________________Date:____________________________________