POLK COUNTY 4-H LEADERS' ASSOCIATION
RECOGNITION SCHOLARSHIP
INFORMATION SHEET
Award:
One $500 scholarship; Other smaller scholarships may
be awarded if money is available.
Purpose of Scholarship:
 To provide recognition of meritorious work and achievement in 4-H and
contribution to the Polk County 4-H Program to outstanding youth.

To encourage 4-H members to continue to participate in 4-H through high
school graduation.

To provide incentive for further education beyond high school.
Eligibility:
Applicant must currently be completing their senior year in high school
(or equivalent program) at the time of application.
Applicant must currently be enrolled in at least one 4-H project and also
have been enrolled for the past 2 years.
Application Requirements: (in the following order)
1) Completion of the attached one-page application form.
2) "My 4-H Story" covering the applicant's whole 4-H career (maximum
three (3) double spaced pages)
3) Submit two letters of recommendation including one from the
applicant's 4-H leader and one other non-family person familiar with the
applicant's academic career and higher education plans.
4) 4-H Records (Must include photo pages)
5) Copy of Transcript of grades
Selection of Scholarship Recipient:
The 4-H Scholarship Committee made up of 4-H Leaders will screen the applications
and select the top applicants for interviews. Scholarship recipients will be announced at
the Polk County Fair awards program.
For more information and an application, contact the Polk County Extension Office.
Applications are due at the Polk County Extension Office by 5:00 on July 1, 2013.
POLK COUNTY 4-H LEADERS' ASSOCIATION
RECOGNITION SCHOLARSHIP
APPLICATION
DEADLINE: July 1, 2013
Please type or write legibly in black ink.
NAME_____________________________________________PHONE_________________
ADDRESS___________________________________CITY________________ZIP_______
HIGH SCHOOL/PROGRAM GRADUATING FROM _________________________________
CUMULATIVE HIGH SCHOOL G.P.A._______ DATE OF GRADUATION ______________
YEARS IN 4-H _______ DATE OF BIRTH _____/_____/_____ MALE___ FEMALE___
4-H Club(s)_______________________________________________________________
4-H Leader(s)_____________________________________________________________
Name and address of institution of higher education you will attend:
_________________________________________________________________________
List the Years that you have helped with fundraisers for the Scholarship Fund? (Pizza and Cards)
__________________________________________________________________________
Major __________________________ Career Plans________________________________
Statement by 4-H Member
I have personally prepared this report and verify that it is correct:
________________________________________________ _________________________
Applicant Signature
Date
Approval of this Application
We have reviewed this report and verify that it is correct:
________________________________________________ _________________________
Parent/Guardian Signature
Date
________________________________________________ _________________________
4-H Leader Signature
Date
(You may use additional paper to answer.)
1.
List the 4-H project(s) you have been enrolled in and years in each project.
2.
Why did you join 4-H?
3.
How have you benefited from your involvement in 4-H?
4.
List 4-H leadership roles and responsibilities you have taken on.
Club:
County:
State:
5.
List 4-H citizenship projects you have participated in.
6.
List school/church/community groups for which you have provided leadership.
7.
Describe the course of study you plan to pursue and why you chose it.
8.
Would you recommend 4-H to other young people? Why/Why not?