Cover Sheet and Checklist
Read entire packet first.
1. Must check with your County 4-H Office for their County Scholarship Deadline
2. All applicants must fill out Section I. Only those believing they qualify for financial aid need to
complete Section II form L.
3. All applications must be typed or filled electronically! Only reference sheets may be
handwritten.
4. Only include last 3 most recent years of 4-H work, from 2009 – 2011.
5. No additional pages may be made to this application.
Checklist
Section I
 Form A - Background Information
 Form B - Employment/Leadership Record
 Form C - Educational Information
 Form D - Projects Record
 Form E - 4-H Leadership
 Form F - 4-H Community Service
 Form G - 4-H Communication Skills
 Form H - Other Activities
 Form I - 4-H Youth Development Report
 Form J - 4-H Foundation Photo Release Form
 Form K – Financial Aid Statement
 Form L - Reference (You should have two Form L’s filled out by different people)
o One from 4-H leader or agent where you are a member
o One from another source: School teacher, Counselor, administrator, past employer, minister, physician
o MAY NOT BE A PARENT/ GUARDIAN
Section II
 Form M - Financial (3 pages)
o Not required if ONLY applying for Merit Scholarships
 Transcripts (These may be copies of official transcripts. Transcripts do not need to be delivered sealed)
 Original plus Three copies of the Entire application (including transcripts and references)
*One reference must be 4-H related (Example: Leader, agent, MAY NOT BE YOUR PARENT/GUARDIAN).
Page 1 of 1
General Information
ARIZONA 4-H YOUTH FOUNDATION EDUCATIONAL SCHOLARSHIPS
ELIGIBILITY AND INFORMATION SHEET
The Arizona 4-H Youth Foundation awards educational scholarships to 4-H members who have college or university
aptitude and capability from funds provided by endowments and donations received to support scholarship awards. Some
awards are based on financial need, others are based solely on merit.
GENERAL INFORMATION

APPLICATION MUST BE TYPED! NO EXCEPTIONS.
 All information is held in strict confidence by Extension personnel, Foundation staff and volunteers serving
on the Scholarship Selection Committee.
 Scholarship funds are deposited with the institution to be attended by the recipient. The institution will be
instructed that one-half of the scholarship is to be paid for the first semester; the second half to be paid for
the second semester, if a "C" average grade, based on 12 or more credit hours, has been maintained.
 Upon notification of award, recipients of educational scholarships must write a thank you letter to
the sponsoring person/organization.
 A copy of this thank you letter, along with a photo release form, an electronic portrait, and a valid
student ID number must be received in the 4-H Foundation office before funds will be deposited with
the educational institution.
ELIGIBILITY



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A new application must be submitted each year.
Original application plus 3 copies must be sent from the County Extension Office First to be
signed, who will then forward to the 4-H Foundation by February 17, 2012 NO EXCEPTIONS.
[Note: Many counties require applications from their members to be turned in up to TWO WEEKS
before the Arizona 4-H Foundations official deadline.]
Must have been a 4-H member a minimum of two full years, which may include the current year.
Involvement during senior year is preferred, but not required.
Former 4-H members from any state and previous recipients who are continuing their education at
an accredited University or Community College in the fall of the year in which the scholarship is
awarded, and who meet the requirement of having been a 4-H member for a minimum of 2 years.
Must submit a completed Arizona 4-H Educational Scholarship Awards application with the Cover
Sheet completed by a 4-H Agent in their respective county. Any incomplete applications WILL
NOT be considered.
Must carry 12 or more credit hours per semester.
County Extension Agent Cover Sheet
4-H Youth Foundation Scholarship Application
Applicant must complete the section below and forward it with your application.
Must be typed!
Date: _____________________
Your County Extension Agent
Specialist:____________________________________________________
Applicant Name
______________________________________________________________________________
Applicant Mailing Address:
______________________________________________________________________
City: ______________________________________ State:_______________ Zip: ____________
Telephone: (____)___________________________ Cell Phone: (____)___________________
Attached is my application for review by the Arizona 4-H Youth Foundation Scholarship Committee.
As requested by the Scholarship Selection Committee, I need the cover sheet/checklist signed by
my County Extension Agent/Specialist.
I would appreciate your forwarding my completed application plus 3 copies with references, to the
Arizona 4-H Youth Foundation Office by February 17, 2012.
Arizona 4-H Youth Foundation
325 Forbes Building- The University of Arizona
PO Box 210036
Tucson, AZ 85721-0036
Thank you!
Applicant Signature: ___________________________________________________________
To be completed by County Extension Agent/Specialist.
I certify that (Applicant) ______________________________________ has obtained legitimate 4-H
references.
County Extension Agent Signature _____________________________________ Date: _________________
+++++++++++++++++++++++++++++++++++++++++++++++
I certify that (Applicant) _______________________________________ is in good standing with
_______________________________ County.
County Extension Agent Signature ________________________________________ Date: ______________
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Background Information- Form A
MUST BE TYPED
Please check the ones that apply:
 This is my first time applying
 I have applied before
 I have received an Arizona 4-H Youth Foundation scholarship before.
Please fill in information below:
Name:______________________________________________________________
(Last, First, Middle)
Date of Birth:_________________________________________________________
Home Address:_______________________________________________________
_______________________________________________________
______________________________________________________
(City)
(State)
(Zip)
Email Address:______________________________________________________
County where you are a 4-H Member:___________________ # of years: _________
If you are eligible for one of these special scholarships, please check and provide the
additional information required. Check out the 4-H Foundation website for
scholarship descriptions: http://cals.arizona.edu/4-h_foundation/scholarships.html
Cochise County Jr. Livestock Merit Scholarship
Exhibited livestock at the Cochise County Fair for a minimum of 3 years
Reference provided by a Cochise County Livestock Council Member
Colorado River 4-H Small Stock Show Merit Scholarship
Exhibited at least one time at the Colorado River Small Stock Show
Attending a 2 or 4 year college
Pima County Horse Project 4-H Merit Scholarship
I have been active in Pima County Horse Project for _____ years.
Pima County Jr. Livestock Sales Merit Scholarship
Pima County Projects completed: Beef Sheep Swine Rabbits Cavy
Poultry Pigeon Pygmy Goats  Market Goat
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Employment Record- Form B
A. Employment (List the two most important activities for which you have been
paid during the past two years).
Employer
Type of Work
Rate of Pay
Length of Service
Hours per
Week
B. Volunteer Employment (List the two most important activities which you
performed for local agencies or individuals as a service without pay. Exclude
4-H activities).
Employer
Type of Work
Length of Service
C. Have you ever served as a National, State or 4-H Club officer
Yes ____ No ____ Office held: ________________________________
Page 5 of 5
Hours per
Week
Educational Information- Form C
In fall 2012, you will be a:
College or University Preference
 College Freshman
 College Sophomore
 College Junior
 College Senior
 Graduate Student
What is your anticipated college graduation date? ___________________________
Name and address of financial office of institution you plan to attend:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
College student ID number (if available): __________________________________
Course of Study
What is your anticipated (or declared) major? ______________________________
What is your anticipated (or declared) minor? ______________________________
High School Information
Academic Information
High school rank is/was: ______ in a class of ______ students.
High school cumulative GPA of: _________ on a 4.0 scale.
SAT score: _____________ or ACT score: _____________
College Information (if applicable)
Cumulative GPA of ______ of on a 4.0 scale.
I certify that the above statements are true, and that if awarded a 4-H Youth Development Scholarship, I will enroll in a
college of my choice in the fall semester of 2012 and will carry a minimum of 12 credit hours and maintain at least a C
average.
Signature of Applicant____________________________________________ Date ___________________________
Further, I agree to allow the Arizona 4-H Youth Foundation to publish quotes and excerpts from the essay portion of
this application to further the efforts of 4-H Youth Development and the University of Arizona Cooperative Extension in
Arizona. (Not signing this section to release quotes will not affect my application in any way)
Signature of Applicant____________________________________________ Date ___________________________
Signature of Parent/Guardian if under the age of 18________________________________ Date ________________
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Projects Record - Form D
Summary of 4-H Projects
List the main projects you have taken and put a check mark in the column for each year that you took that project.
Project
Page 7 of 19
Year Year Year Year Year Year Year Year Year
4H leadership - Form E
4-H Leadership
List the most significant 4-H leadership experience(s) that you have had. Examples: Elected or appointed
office held, committee chaired or served on, junior or teen leader, helping younger members, Youth Adult
Council or any role(s) that involved development of leadership skills. If you have not had any leadership
experiences enter the year and then write “None” or “N/A” which means, Not Applicable.
Year
Position
Held
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Club/Project
What was your role? What did you do?
Community Service - Form F
4-H Community Service
List up to four 4-H Community Service activities in which you participated as a group or individually.
Examples: Sharing your time by visiting a retirement home or hospital, helping with a community event
(such as Friends of the Library book sale), serving others, donating time or items to individuals or groups in
need, and/or beautification projects. You can use more than one line to explain your service project, if
needed.
Year
Club/Group
Conducting project
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2
Arizona Cooperative Extension
Service project description/ what did
you do?
Hours
spent
(Add more pages if needed)
Communication Skills - Form G
4-H Communication Skills
List up to four of your 4-H demonstrations, illustrated talks, prepared talks, and/or speeches. Also record the
level. A Demonstration is showing how to do something using props. An Illustrated talk is telling about
something using props. Prepared talks or speeches are well-prepared presentations without props, and
should be at least 2-5 minutes long. Use of notes for talks and speeches is acceptable.
Year
Title of Demonstration, Talk, Description
Speech, Activity, Website
Development, News Article
written, TV or radio
presentation.
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Number of
times/
Where
Other Activities - Form H
Participation Other than 4-H
List here your participation in any other youth development or community organizations and check the year.
Other youth
development or
community
organizations
Page 11 of 19
Year
Year
Year
Year
Year
Year
Year
Year
Year
4-H Youth Development Report- Form I
Applicant Name: _____________________________________________________
(Last, First, Middle)
This is a personal statement. Please write a well-developed essay detailing your 4-H career and what is has meant to
you. Include proper use of spelling and grammar. It does not have to include all projects, demonstrations, etc. in which
you have participated or all offices or committee assignments which you have held. Rather give the highlights of you
4-H career and how it has affected you. The paper must be typed, 12 point font, double spaced and no more than one
page. PLEASE NO MORE THAN 300 WORDS. TYPED REPORTS ARE REQUIRED!
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4-H Foundation Photo Release Form - Form J
PHOTO RELEASE FORM
I grant permission to The Arizona 4-H Youth Foundation, a non-profit educational organization,
separate from the University of Arizona, but sanctioned by the Board of Regents, University of Arizona
administration, and the College of Agriculture & Life Sciences and Cooperative Extension to use
photographs taken of me on the date and at the location listed below for use in publications such as
recruiting brochures, newsletters, and magazines, and to use the photographs on display boards, and
to use such photographs in electronic versions of the same publications or on websites or other
electronic form or media, and to offer them for use or distribution in University publications, electronic or
otherwise, without notifying me.
I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter
that may be used in conjunction with them now or in the future, whether that use is known to me or
unknown, and I waive any right to royalties or other compensation arising from or related to the use of
the photograph.
I hereby agree to release, defend, and hold harmless The Arizona 4-H Youth Foundation, the Arizona
Board of Regents, on behalf of The University of Arizona and its agents or employees, including any
firm publishing and/or distributing the finished product in whole or in part, whether on paper or via
electronic media, from and against any claims, damages or liability arising from or related to the use of
the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or
use in composite form, either intentionally or otherwise, that may occur or be produced in taking,
processing, reduction or production of the finished product, its publication or distribution.
I am 18 years of age or older and I am competent to contract in my own name. I have read this release
before signing below, and I fully understand the contents, meaning and impact of this release. I
understand that I am free to address any specific questions regarding this release by submitting those
questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and
knowledgeable acceptance of the terms of this release.
__________________________________________________________________________________
Location of Photo
Date
Name_____________________________________________________________________________
(Please Print)
Signature__________________________________________________________________________
Signature of guardian (if under 18 years of age)____________________________________________
April 18, 2007 Photo Release form
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Financial Aid Statement-Form K
Why do you feel you need financial aid? Note any circumstances not previously
given which indicate your financial need (Must be typed, 12 point font, double
spaced, and no more than one page. 300 word maximum)
I certify that, to the best of my knowledge, the above information is accurate and
complete.
Signature of Applicant ________________________________________________________ Date________________
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4-H Youth Development Educational Scholarship Award
Reference –Form L
This page may be hand written.
Applicant Name: ________________________________________________________________________
How long have you known the applicant? ____________________________________________________
Your relationship to the applicant: __________________________________________________________
Your name and address:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Rate the applicant named above on each of the characteristics listed below by
circling your score. Please comment on your rating.
Characteristic
Comments/Score (5=high; 1=low)
A. Capacity to achieve (Chance for Success)
5
4
3
2
1
Comment:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
B. Reliability (Integrity, Promptness, etc.)
5
4
3
2
1
Comment:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Why do you recommend this applicant for an educational scholarship? Please be specific.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature________________________________________________________________
Date:______________________________________
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4-H Youth Development Educational Scholarship Award
Reference –Form L
This page may be hand written.
Applicant Name: ________________________________________________________________________
How long have you known the applicant? ____________________________________________________
Your relationship to the applicant: __________________________________________________________
Your name and address:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Rate the applicant named above on each of the characteristics listed below by
circling your score. Please comment on your rating.
Characteristic
Comments/Score (5=high; 1=low)
A. Capacity to achieve (Chance for Success)
5
4
3
2
1
Comment:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
B. Reliability (Integrity, Promptness, etc.)
5
4
3
2
1
Comment:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Why do you recommend this applicant for an educational scholarship? Please be specific.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature________________________________________________________________
Date:______________________________________
Page 16 of 19
Section II
Financial Statement- Form M
Complete this section only if you are applying for a financial
scholarship.
Please Type
Applicant’s Name: _______________________________________________
(Last, First, Middle)
Applicant’s Income & Expenses
Total personal income (use 2011 tax figures)
$_________
Source(s) of income: _____________________________________________________
Anticipated personal income for 2012
$__________
Source(s) of income: _____________________________________________________
Applicant’s Assets:
Cash, Savings, and Checking Accounts (as of today)
Value of Trusts
Market Value of Stocks and Bonds
Total Value of Assets
$_________
$_________
$_________
$_________
Applicant’s Debts
Specify: __________________________________
Specify:___________________________________
$_________
$_________
Total amount of outstanding debts
$_________
Applicant’s Anticipated Expenses for Academic Year
Housing
Food
Medical
Transportation
Tuition and Fees
Books and School Supplies
Clothing
Recreation and Gifts
Other:_________________________________________
Total anticipated expenses
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
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Parent(s) Financial Statement- Form M Continued
(Not needed if applying for merit scholarship)
Parent(s) are: Separated, Year ________  Divorced, Year ______
 Married Single
Deceased
Applicant Lives with: __________________________________________________
Who will claim the applicant as a tax exemption for 2011? _____________________
2010 Income as reported on your 2010 federal tax form:
Father’s adjusted Gross Income
Mother’s adjusted Gross Income
Other taxable income
Nontaxable income and benefits
Total 2010 income
2011 Income
Father’s adjusted Gross Income (Wages, Salary. Etc…)
Mother’s adjusted Gross Income (Wages, Salary. Etc…)
Other taxable income
Nontaxable income and benefits
Total anticipated 2011 income
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
Parent(s) Educational Support of Children
How many people currently reside in your household? ___________________________________
How many of these are dependent children? __________________________________________
Anticipated contribution by parents toward applicant’s education and living expenses for the next
12 months following enrollment in college.
$__________
Amount of yearly contribution toward educational or living expenses of other children currently
enrolled in college. Number of children this represents __________
$__________
Total support
$___________
I certify that, to the best of my knowledge, the above information is accurate and complete.
Parental Signature _______________________________________Date ____________________
Page 18 of 19
Form M Continued
List all grants and scholarships for which applicant has applied for the 2012-2013 school year.
Name of Grant or Scholarship
Amount
Awarded*
*Check those that have been awarded for the 2012-2013 academic year.
Financial Assistance Programs (Amount of assistance applicant will receive form)
Financial Assistance Programs
Social Security
War Orphan’s Benefit
Welfare Benefits
A.F.D.C.
Other
Total Special Assistance
Amount
Family
Father’s name and address:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Mother’s name and address:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Guardian’s name and address:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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