CAMPBELLSPORT SCHOLARSHIP FOUNDATION/
2014 PAT & MARILYN O'BRIEN
AGRICULTURAL SCHOLARSHIP FORM
114 W. Sheboygan Street
Campbellsport, WI 53010
APPLICATION FORM - Due by noon on Friday, February 7, 2014 in the District Office
1. Applicant must be a past graduate of Campbellsport High School or in the current CHS
graduating class, pursuing a career in an Ag related field, to be eligible for this scholarship.
2. Past Agricultural Scholarship winners are NOT eligible.
Date ____________________
I. Personal Data
1. Name
___________________________________________________________________
Last
First
Initial
Age
2. Home Address _________________________________________________________________________
Number
Street
3. Telephone Number (_____)______________________
4.
City
Date of Birth _______________________
Marital Status _________________________________
5. Name of Parents, Guardian, or Nearest Relative _______________________________________________
Address _____________________________________________________________________________
6. Attach one recent personal photograph (preferably 2" x 3").
II. Supplementary Data
1. Which Ag short course, university, college, or technical college do you expect to attend? _____________
____________________________________________________________________________________
2. What major or vocational goal do you plan to study during your post secondary education? ___________
____________________________________________________________________________________
3. How much do you think it will cost you to attend the school of your choice for one year?
(a) Tuition $____________________
(b) Estimate Living Expenses $____________________
4. What efforts have you made toward saving for college expenses? (Please explain) _________________
___________________________________________________________________________________
5. Do you plan to do outside work while attending school? (Explain briefly) ________________________
___________________________________________________________________________________
6. Education Experience (most recent first)
School
Location
Dates Attended
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
7. a.
b.
High School Numerical Average
____________________
High School Class Rank
____________________
8. Leadership qualities can be demonstrated both within and outside the school setting. On a separate sheet(s) of
paper please provide the following information, indicating the extent of your involvement (years) and any
awards or recognition received, as well as offices held.
a.
Leadership roles: 4H, FFA, scouting, church groups, political organizations, etc.
b.
Community service: organizations, volunteer groups, etc.
c.
Extra-curricular activities: forensics, student government, athletics, etc.
d.
Employment while at school: type of work, hours per week, etc.
9. List three references (nonrelatives) that will be forwarding letters of recommendation.
Name _____________________________________________
Telephone Number _________________
Address ______________________________________________________________________________
Name _____________________________________________
Telephone Number _________________
Address ______________________________________________________________________________
Name _____________________________________________
Telephone Number _________________
Address ______________________________________________________________________________
Applicant must notify the individuals listed above that the letters of recommendation will not be accepted after noon
on February 7, 2014 . The letters of recommendation may be submitted with the application or mailed to:
Campbellsport Scholarship Foundation, Scholarship Committee, 114 W. Sheboygan Street, Campbellsport, WI
53010
III. Personal Statements
On a separate sheet of paper write:
a.
A 300 word essay to explain your vocational or professional goal and relate how past, present, and future
activities make the accomplishment of this goal probable. (The applicant by deed and circumstance must
demonstrate his/her worthiness.)
IV. Foundation award winners are expected to make an acceptance speech at the Campbellsport FFA banquet
ceremonies in April.
AUTHORIZATION FOR RELEASE OF RECORDS
I authorize the release of all my student records including: my academic record, grade point average,
rank in class, test scores, etc. to the scholarship committee. Finally, I affirm the data I have
submitted is correct to the best of my knowledge. Note: If applicable, the applicant must send
current and official (original signature), post secondary education grades, and test scores to the
committee.
____________________________________
Signature of applicant
____________________________________
Signature of parent if applicant is under 18
____________________________________
Date