Return to:
University of Illinois Extension
DuPage County Office
1100 E Warrenville RD - Suite 170
Naperville, Illinois 60563
Attention: 4-H Scholarships
2016
DuPage County 4-H Foundation
SCHOLARSHIP APPLICATION
Your completed application must be filled out in full and received at the above address by
4:00 p.m., Thursday, April 21, 2016. An incomplete or late application will NOT be
considered.
1.
Applicant’s Name:
(Please print full name)
Address:
City, State, ZIP:
Telephone Number:
Date of Birth:
Name of parent(s)/guardian(s):
Address:
Telephone Number: (
)
Email address: ___________________________________________________
2.
High School Graduation:
2016
2015
Name of High School:
Address:
Telephone Number: (
)
Guidance Counselor Name:
Guidance Counselor Phone:
Other schools attended (if any):
3.
Have you applied and been accepted to a College/Trade School? Yes
No
Name of school:
Address:
Town, State, ZIP:
Field in which you plan to major:
How many credit hours per quarter/semester will you be taking?
What are your future career plans?
4.
Practical or Work Experience: List all jobs (paid/unpaid) held since the age of
15, including work at home for parents and part-time employment while in
school. Begin with the most recent:
Dates Held
Job/Position Held
Employer/Address
5.
Record of 4-H Club Work: (attach additional sheet, if needed)
Number of years enrolled in 4-H:
Club Name:
Number of years in DuPage Co. 4-H (4 years minimum required):
Total years as a Junior Leader:
Offices held in local club:
Other leadership activities in club:
Special 4-H awards received:
Special 4-H trips, conferences, etc., attended at Regional, State, or National
level:
6.
Project Summary: List below the MAJOR projects you have enrolled in during
your 4-H membership: (attach additional sheet, if needed)
A. Project:
No. of years enrolled
Community Service, Citizenship and Leadership Activities Related to Project:
Recognition related to project (medals/trophies, State Fair delegate, etc.):
B. Project:
No. of years enrolled
Community Service, Citizenship and Leadership Activities Related to Project:
Recognition related to project (medals/trophies, State Fair delegate, etc.):
C. Project:
No. of years enrolled
Community Service, Citizenship and Leadership Activities Related to Project:
Recognition related to project (medals/trophies, State Fair delegate, etc.):
7. Other 4-H Activities: List your participation in demonstrations, talks, radio, and TV
appearances, newspaper articles written, tours, camp, judging events, etc. List
other leadership experiences, such as camp counselor, junior superintendent,
county program committees, etc. (attach additional sheet, if needed)
8.
Other Activities (NOT 4-H): List activities, accomplishments, and leadership
experiences (religious, school, other youth groups, etc.) (attach additional sheet,
if needed)
9. References: List the names, addresses, and occupations of two (2) people you
have asked for references, one of whom MUST be or have been your 4-H leader.
The reference letters are to be returned with this application.
Name
Address
Occupation
Signatures:
Date
(Signature of Applicant)
Date
(Signature of Parent/Guardian)
PLEASE NOTE:
Attach your 4-H Story, not to exceed two pages (8½” x 11” paper). Try to convey how
your participation in 4-H:

contributed to your self-respect and concern for others; and

influenced you in school, your use of leisure time, and career plans.
You may wish to include special interests and unusual situations you encountered and
some things you tried, successfully or unsuccessfully. Include how 4-H helped you
learn things you didn’t know before.
To be complete, your application MUST include the following:
 your 4-H story
 letter of application to and/or letter of acceptance from an accredited college
or trade school (or proof of enrollment, if you are already attending college)
 two reference letters, one of which MUST be from your 4-H leader