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ARIZONA 4-H YOUTH FOUNDATION EDUCATIONAL SCHOLARSHIPS
2013 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 – 2012.
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 Statement
Form J – Financial Aid Statement
Form K - Reference (You should have two Form K’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 L - 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 18
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, 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






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 15, 2013 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 minimum number of credits per semester required to be full time student.
Page 2 of 18
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 Representative:_________________________________________
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/Representative.
I would appreciate your forwarding my completed application plus 3 copies with references, to the
Arizona 4-H Youth Foundation Office by February 15, 2013.
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: ______________ Page 3 of 18
Background Information- Form A
Please check the ones that apply:
MUST BE TYPED
 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)
EmailAddress:______________________________________________________
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 Arizona 4-H Youth 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 Page 4 of 18
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 4-H Club officer?
Yes ____ No ____ Office(s) held: __________________________________
______________________________________________________________
Page 5 of 18
Hours per
Week
Educational Information - Form C
In fall 2013, you will be a:
 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:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Course of Study
What is your anticipated (or declared) major? ______________________________
What is your anticipated (or declared) minor? ______________________________
Academic Information
College Information (if applicable)
Cumulative GPA of ______ on a 4.0 scale (not weighted). College student ID number ________
High School Information
High school rank is/was: _________ in a class of _________ students.
High school cumulative GPA of: _________ on a 4.0 scale (not weighted).
SAT score: _____________ or ACT score: _____________
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 2013 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 ______________
Page 6 of 18
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
Year
Year Year Year Year Year Year Year Year Year
Sample
years 20042003- 2005
20052006
20062007
20072008
X
X
20082009
20092010
20102011
20112012
20122013
X
X
2004
Sample Project – Vet Science
(Leave this box empty)
(Begin entering Project names here)
Page 7 of 18
X
X
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
Page 8 of 18
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
Page 9 of 18
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, website development,
news articles, TV or radio presentation 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, Speech, Activity,
Website Development,
News Article written, TV or
radio presentation.
Page 10 of 18
Description
# of times/
Level:
L=Local,
S=State
N=National
Other Activities - Form H
Participation Other than 4-H
List here your participation in any other youth development or community organizations and note
the year.
Year
Other youth
development or
community
organizations
Page 11 of 18
Description of activity
4-H Youth Development Statement - 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 your 4-H career and how it has
affected you. This page must be typed, 12 point font, double spaced and no more than one page.
PLEASE NO MORE THAN 1750 CHARACTERS, THIS PAGE HAS BEEN RESTRICTED TO THIS
NUMBER. TYPED REPORTS ARE REQUIRED!
Page 12 of 18
Financial Aid Statement-Form J
Describe why you feel a need for financial assistance. Note any circumstances not previously given
which indicate your financial need or compelling reasons for earning a scholarship. This page must
be typed, 12 point font, double spaced and no more than one page. PLEASE NO MORE THAN
1750 CHARACTERS, THIS PAGE HAS BEEN RESTRICTED TO THIS NUMBER. TYPED
REPORTS ARE REQUIRED!
I certify that, to the best of my knowledge, the above information is accurate and complete.
Signature of Applicant _______________________________________ Date________________
Page 13 of 18
4-H Youth Development Educational Scholarship Award
Reference – Form K
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 14 of 18
4-H Youth Development Educational Scholarship Award
Reference – Form K
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 15 of 18
Section II
Financial Statement- Form L
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 2012 Taxable Earnings)
$_________
Source(s) of income: _____________________________________________________
Anticipated personal income for 2013
$__________
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
$_________
Page 16 of 18
Parent(s) Financial Statement- Form L 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 2012? _____________________
2011 Income as reported on your 2011 federal tax form:
Father’s adjusted Gross Income
Mother’s adjusted Gross Income
Other taxable income
Nontaxable income and benefits
Total 2010 income
$__________
$__________
$__________
$__________
$__________
2012 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 2012 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 17 of 18
Form L Continued
List all grants and scholarships for which you have applied for the 2013-2014 academic year.
Name of Grant or Scholarship
Amount
Awarded*
*Check those that have been awarded for the 2013-2014 academic year.
Financial Assistance Programs (Amount of assistance applicant will receive)
Financial Assistance Programs
Amount
Social Security
War Orphan’s Benefit
Welfare Benefits
A.F.D.C.
Other
Total Special Assistance
Family
Father’s name and address:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Mother’s name and address:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Guardian’s name and address:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Page 18 of 18