DUSTIN AND KRISTEN YODER MEMORIAL FOUNDATION, INC.
SCHOLARSHIP APPLICATION
**** APPLICATION DEADLINE: March 15th, 2013****
Download this form to your computer and save it as a document, then type your answers in the
fields provided. You may need to click "enable editing" if a box appears at the top with
"Protected view". Advance to each subsequent field by using your tab key or clicking on each
new box with your mouse. Answer as thoroughly as possible. If an item does not apply to you, put
"N/A" in the field. Your essay should be clearly written but succinct. If submitting by email, your
completed application must have your digital signature and that of your parents or guardians if
you are under age 18. If delivering or mailing, your completed application must have handwritten
signatures. Applications without necessary digital or handwritten signatures will not be accepted
or considered. Save the application with your answers once you have completed the application.
To submit your application, email it prior to the application deadline stated above to BOTH of the
following: Nicole.Harris@nau.edu (Nicole Harris ----Administrative Assistant at the Department
of Geography Planning and Recreation at NAU) and yoderken@gmail.com (Ken Yoder---President of Dustin and Kristen Yoder Memorial Foundation, Inc.) You may also print your
application and return it in person to Nicole Harris at the Geography, Planning and Recreation
office, Room 201, SBS West (building 70) and by mail to Ken Yoder, 5634 Gebert Road, Muldoon,
Texas 78949.
PERSONAL INFORMATION
Applicant's Name
Last
Phone
-
First
MI
-
Mailing Addresses:
Permanent
Number, Street, Apt. No. (if any), City, State and Zip Code
Local
Number, Street, Apt. No. (if any), City, State and Zip Code
Sex
M
F
Date of Birth
/
M D
/
Email
Year
Citizenship (country)
Country where you were born
Marital Status
Single
Married
Divorced
Separated
ACADEMIC ACHIEVEMENT
Approximate number of credits left to graduate (after this semester)
Expected College Graduation Date
College Major
/
(month/year)
College Minor or Merged Major
Estimate the number of hours you will be taking next fall
Cumulative NAU GPA
and next spring
Number of NAU Credits
Major (Department) GPA
Provide an academic summary of your last four (if possible) semesters of full-time enrollment. This
academic history could be from NAU, another 4-year college or university, a community or junior
college, or any combination of these. Grade points are calculated by giving an ‘A’ 4 grade points for
each credit; a ‘B’, 3 grade points; a ‘C’, 2 grade points; and a ‘D’, 1 grade point. The GPA is then the
total grade points divided by the total credits.
Institution’s Name
Semester and
Year
Number of Credits
Earned
Semester GPA
FINANCIAL INFORMATION
Dependency Status:
Dependent for Tax Purposes
Not a Dependent for Tax Purposes
Do you have any other scholarships for the coming year?
% Self-Supporting (approximate)
yes
no. If so, list in the field below.
Significant or pertinent jobs over the last several years:
Start Date:
/
Month/Year
Termination Date:
/
Month/Year
Name of employer (address, phone number, contact person if known)
Description of Job
Start Date:
/
Month/Year
Termination Date:
/
Month/Year
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Name of employer (address, phone number, contact person if known)
Description of Job
Start Date:
/
Month/Year
Termination Date:
/
Month/Year
Name of employer (address, phone number, contact person if known)
Description of Job
Start Date:
/
Month/Year
Termination Date:
/
Month/Year
Name of employer (address, phone number, contact person if known)
Description of Job
Start Date:
/
Month/Year
Termination Date:
/
Month/Year
Name of employer (address, phone number, contact person if known)
Description of Job
How do you plan to finance the rest of your education (loans, scholarships, grants, employment, workstudy, etc.)?
AWARDS AND ACTIVITIES
List in reverse chronological order (most recent to least recent) in the field below high school or college
clubs and organizations with which you have been involved. Include honors, awards, offices held,
responsibilities taken on, etc.
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List in the field below any other outdoor activities, leadership programs, or courses you have taken or in
which you participated.
ESSAY
In the field below, please explain why this scholarship is important to continue your education. Include
comments on your career goals and how you plan to use your outdoor leadership training upon
graduation. Your application will in part be judged on the quality and content of your written statement.
This field is limited to 3000 characters, so please be succinct.
ADDITIONAL INFORMATION (not required but may be helpful)
Briefly comment on other factors or information about you, your family, or your financial situation that
the Scholarship Committee ought to consider that may be helpful in reaching its decision. This field is
limited to 1000 characters.
CERTIFICATION AND AGREEMENT
I am hereby applying for a scholarship from the Dustin and Kristen Yoder Memorial Foundation,
Inc. I certify that the above information is true, accurate, correct and complete to the best of my
knowledge. If I receive a scholarship award from the Foundation, I agree to participate in and complete
the outdoor education or outdoor leadership course or program set forth in this application, and I
acknowledge that upon completion of the course or program, I will be required to provide to the
Foundation a written statement of the value of the course or program to me and my plans for continued
outdoor education. I also understand that Northern Arizona University will provide the Foundation with
a report of my successful completion of the course or program. I understand that I am responsible for
gaining admission to the N.A.U. Outdoor Leadership Program, for all costs associated with such course
or program, and that a scholarship award may only be for a portion of the course or program listed
above. Once the Foundation has awarded a scholarship, I cannot change the course or program without
the express written consent of the Foundation and the educational institution. I understand that a
scholarship may be revoked for any of the following reasons: (a) withdrawal from or failure to complete
the course or program listed above; (b) inability to secure admission or enrollment to the course or
program listed above; (c) evidence of misconduct; (d) failure to submit reports as required; (e) changing
courses or programs without the prior written consent of the Foundation; (f) providing any false or
misleading information on this application or any other information provided to the Foundation. I
understand that revocation of a scholarship shall cause all payments to cease and may make me liable for
return of payments previously provided. I hereby consent to release of my academic, financial, and/or
any other information as required by NAU or by the Foundation.
I understand and agree that the Dustin and Kristen Yoder Memorial Foundation, Inc., its
directors, officers, representatives and agents are in no way liable for my personal welfare or safety in
any outdoor education or leadership course or program in which I choose to participate, and are not
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responsible for enabling me to pursue my studies. The Dustin and Kristen Yoder Memorial Foundation,
Inc., its directors, officers, representatives and agents assume no responsibility, liability or obligation
whatsoever beyond providing the monetary scholarship award.
Date: / /
Signature of Applicant
Month/Day/Year
(type in signature and date if emailing application; handwrite signature and date if delivering and
mailing application)
Date: / /
Signature of parent or guardian (if applicant under 18)
Month/Day/Year
(type in signature and date if emailing application; handwrite signature and date if delivering and
mailing application)
Date: / /
Signature of parent or guardian (if applicant under 18)
Month/Day/Year
(type in signature and date if emailing application; handwrite signature and date if delivering and
mailing application)
If you submit your application by email, then typing your name(s) in the spaces above constitutes
your digital signature and your agreement to submit this application by electronic means and our
agreement to accept delivery of and to consider your application by electronic means, as described
in Arizona Revised Statutes Section 44-7001 et seq. Your electronic signature has the same legal
effect as your handwritten signature. You represent and warrant that the electronic signature
above is the act of the person whose name appears in the signature space. If you print your
application and submit it by mail, then you must sign your name(s) and date in the space provided
above.
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