Arkansas Extension Homemakers Council Enrollment Card	FCS375 4-2014
Date
Name
Race/Ethnic American Indian/Alaskan Native Asian Black Hispanic Native Hawaiian/Pacific Islander
White Two or More
Street Address
City	Zip Code
County	E-mail
Phone	( ) -
Member of EHC since (date)
Club Name

This information is requested solely for the purpose of determining compliance with federal civil rights law, and your response will not affect your eligibility to participate in Extension programs. By providing this information, you will assist us in assuring that this program is administered in a nondiscriminatory manner.