To:
Current High School Senior 4-H Members
From: Margaret Schmid, 4-H Foundation Chairperson
Re:
DeWitt County 4-H Foundation Scholarship
Date:
September 2008
Attached is the DeWitt County 4-H Foundation scholarship application. Please note that you are to submit
your cumulative DeWitt County 4-H Member Record. If you do not have a record form, please contact the
Extension office at 217/935-5764.
Scholarships are $500 each. Scholarships do not have to awarded annually by the Foundation.
If you have any questions, please call Sherry Fulton at the Extension office.
The scholarship deadline is March 20, 2009. The application and all supporting materials must be
submitted by 4:30 p.m. on this date. Check the list to make sure you have all materials: application form,
4-H Member Record, 4-H story and two reference letters. One reference letter is to be from your 4-H club
leader.
The scholarship committee will conduct interviews the morning of April 4, 2009.
Enc.
DeWitt County 4-H Foundation Scholarship Information
1.
Eligibility
 current high school senior student
 current enrolled DeWitt County 4-H member by January 1, 2009
 traditional 4-H club member in DeWitt County for four years
 proof of acceptance to an accredited school, college or training center for fall 2009
2.
The scholarship will be awarded on a combined basis of merit and 4-H accomplishment,
4-H records, interview and references.
3.
The recipient may enter any college or technical school of their choice in any degree program.
4.
Payment: The first payment of $250 will be paid after the Extension office receives proof of
acceptance for schooling. The second payment of $250
office receives a copy of grades showing
will be made after the Extension
(good standing) from the first semester studies
and proof of returning to school second semester. The total scholarship is $500.00.
5.
References: Ask the individuals to complete the reference form put it in a sealed envelope.
The envelope should then be attached to the application when you submit it. Candidates are
to have two references. One reference is to be from your 4-H leader.
6.
The scholarship winner/winners will be introduced at the DeWitt County 4-Hfair award
program in July.
7.
Applications and materials are due by March 20, 2009, 4:30 p.m. Return your application to
the University of Illinois Extension, DeWitt County, 4-H Foundation, RR# 3 Box 289U, Clinton,
IL 61727.
8.
Scholarships do not have to be awarded annually by the Foundation board.
9.
The Foundation board requests the scholarship winner/winners display their records and
memorabilia at the 4-H show to encourage 4-H members to set their goals for achievement.
10.
The Foundation board may contact a scholarship winner to speak at the 4-H achievement
program or other events.
The DeWitt County 4-H Foundation Scholarship Award Committee will use the following
scoring system to determine the scholarship winner/winners.

maximum of 40 points for 4-H records - DeWitt County 4-H Member Record Form

maximum of 35 points for 4-H accomplishments

maximum of 15 points for the interview

maximum of 10 points for 4-H story
11.
Summary of materials to be submitted.
 4-H Foundation Scholarship Application
 Two reference forms to be attached (in sealed envelopes) to application by March 20
 DeWitt County 4-H Record
 4-H story (What your entire 4-H career has meant to you)
12.
Additional pages may be used as needed to complete any area of the application/materials.
13.
Interview date with scholarship committee is set for Saturday morning,
Dated: September 2008
April 4, 2009.
DeWitt County 4-H Foundation Scholarship Application
Name
Year
Enrolled by January 1, 2009, in DeWitt County 4-H club:
Years in 4-H:
Yes
No
Date of last enrollment:
Name you want used in publicity:
(print)
Home address:
Zip code:
School address:
Home phone number: (
Zip vode:
)
Social Security Number:
Age January 1 this year:
Parents/Legal Guardians:
Father’s name & address:
Occupation:
Mother’s name & address:
Occupation:
Name & address of school you will attend this fall:
Date of birth
/
/
What career do you plan to follow?
I personally have prepared this report and certify that it accurately reflects my work.
Date:
Signature of 4-H member
We have reviewed this report and believe it to be correct.
Date:
Signed
(Parent or Guardian)
Date:
Signed
(4-H Leader)
4-H Foundation Scholarship Application - page 2
1.
What are your reasons for choosing to pursue an education beyond high school?
2.
In what field are you majoring or planning to major in and why?
3.
Major 4-H projects. (List 4-H project areas in which you have enrolled and completed
projects. State the number of years you were enrolled in each project.)
4.
Major 4-H project awards. (List major project awards and recognition you have received
in 4-H -- local, county, state, national.)
Year
Project
Award
Level
5.
Project related accomplishments. (What do you think are your most significant “project
related” accomplishments and “project related” involvements.)
4-H Foundation Scholarship Application - page 3
6.
Major 4-H awards and honors. (List awards which are not listed as 4-H project awards
in question four, such as the I Dare You Award, Key Award, etc.)
Year
Type of Award
For What Received
Level
7.
Major 4-H offices held. (List 4-H offices held, including club, county, district, state.)
8.
Major community activities. (List citizenship/community service activities. Include those
things which contribute to the welfare of your community, other individuals, or organizations in
which you are a member.)
9.
What is your fondest memory of 4-H?
DeWitt County 4-H Foundation Scholarship
Reference Form
Name of Applicant
Name of Evaluator
Position or Title
Address
(city, state & zip)
Please rate the applicant according to the following scale:
(0 unknown and 1 poor to 5 excellent)
Leadership & Teamwork
1.
Works effectively with everyone in a group.
0
2.
2
3
4
5
Communicates ideas effectively.
0
3.
1
1
2
3
4
5
Takes responsibility and follows through.
0
1
2
3
4
5
4.
Contributes a fair share of work to a group effort.
0
1
2
3
4
5
Citizenship
1.
Participates in community service activities.
0
2.
1
2
3
4
5
Works well with diverse audiences.
0
1
2
3
4
5
(over)
Interpersonal Skills
1.
Gets along well with others.
0
2.
3
4
5
1
2
3
4
5
Displays respect for ideas of others.
0
4.
2
Has a positive attitude.
0
3.
1
1
2
3
4
5
Uses good judgement when opposed to ideas or projects.
0
1
2
3
4
5
In the space provided please offer any additional comments regarding the applicant.
How do you know the applicant? (i.e. teacher, 4-H leader, etc.)
Signature of Evaluator
Date
Please place in a sealed envelope and return to applicant to submit with application.