Revised 5/29/2013
Tarrant 4-H Adult Leader Association
Scholarship Program Application
Application and any required documents must be received in the 4-H office by June
7, 2011.
June
20,
2014
PERSONAL DATA
Last Name:
_______________________________________________________________________________
First Name:
_______________________________________________________________________________
Mailing Address:
_______________________________________________________________________________
City, State, Zip:
_______________________________________________________________________________
Home Phone:
__________________________________
Email Address:
_______________________________________________________________________________
Age (as of 6/1/13): _________
Cell Phone:
____________________________
Grade Level: _______Number of years you have been in 4-H: ____________
Number and years of recordbooks completed__________________________________________________________
College or University to which you have applied: _______________________________________________________
Planned Major Course of Study: ____________________________________________________________________
APPLICATION CERTIFICATION
I certify that the information contained herein is correct and truthfully reflects my personal, 4-H and academic background and
records. I agree that, if any information contained herein is found to be falsified in any way, my application will automatically
become null and void.
I hereby authorize any person, firm, or entity to release to the donor’s representative, information concerning the subject matter
of the statements I have made in this application, including, but not limited to, information concerning my academic record,
activities, honors and awards, citizenship or residency, and financial situation. A copy of this authorization is agreed by the
undersigned to have the same effect and force as original. Any person, firm or entity releasing matters pursuant to this
authorization is hereby absolved from liability.
Signature of Applicant:
_______________________________________ Date: ________________________
Signature of Parent/Guardian: _____________________________________
Date: ________________________
Signature of Manager: ___________________________________________
Date: _________________________
I certify that the applicant has been enrolled in the Tarrant County 4-H Program during all or part of the 2012-2013 4-H year.
Signature of CEA:
_______________________________________
Date: ________________________
2
RECORD OF EXPERIENCE
4-H PROJECTS: List up to four (4) of your most significant 4-H projects throughout your 4-H career. Describe years involved,
knowledge and skills gained, scope and activity related to projects, demonstrations, talks, exhibits, workshops, tours, interviews,
etc. Describe why these projects were important and what impact your involvement provided you to have on other people. Put
emphasis on the quality of your experience rather than quantity. Please reference the level of participation/involvement as
L=local, C=county, D=district, R=region, S=State, N=National, and I=International. DO NOT ADD PAGES.
3
RECORD OF EXPERIENCE
4-H LEADERSHIP ROLES: List up to your top twenty-five major 4-H leadership roles throughout your 4-H career. Include
volunteer, promotion, and elected/appointed leadership. List roles and responsibilities, years, levels of involvement (L=local,
C=county, D=district, R=region, S=State, N=National, and I=international), duties and accomplishments. Put emphasis on the
quality of your experience rather than the quantity.
Year
Leadership Role
Level of
Involvement
Role, Responsibility, Duties, Accomplishments
(Brief Statements)
4
RECORD OF EXPERIENCE
4-H CITIZENSHIP AND 4-H COMMUNITY SERVICE: List up to your top fifteen citizenship and 4-H community service
activities. List activity, year, and role (Y=yourself; M=member of a group; P=provided primary leadership) Put emphasis on the
quality of your experience.
Year
Activity
Role (Y=yourself; M=member;
P=provided leadership)
Hrs.
Why was it important and and/or impact of
involvement?
5
RECORD OF EXPERIENCE
4-H HONORS: List your most important honors received through 4-H.
Year
Award
Level of Award
Why is this award important to you?
L=local; C=county; D=District;
R=Regional; S=state
NON-4-H ACTIVITIES – LEADERSHIP, HONORS, and COMMUNITY SERVICE: Describe how you spent time outside of 4-H,
why you devoted time to a particular activity, and the impact the activity had on your personal development and others. (Include
school, church, other youth groups, etc.)
6
PERSONAL NARRATIVE
Describe how 4-H has impacted your life. Please include any information you would like to convey to the judges that you may
not have already stated within this application. (Please do not duplicate previous answers within this application.)
7
CAREER NARRATIVE
Describe how you have prepared yourself to have an awareness and understanding of career(s) applicable to the degree you
wish to pursue. (College visits, investigations of career opportunities, persons or experiences that influenced you, etc.)
8
The Tarrant 4-H Adult Leaders Association may award a Millie Hurst Scholarship and a Mark Green
Scholarship. (Due to limited funds, a youth is limited to one TALA sponsored scholarship per 4-H member
career.) Eligible members may apply for either or both, using a single application. Please read the
requirements for each scholarship and certify in each area for which you wish to apply.
Applicants for the Millie Hurst Scholarship:
Please Read Eligibility Requirements and Certify:





I am a Tarrant County 4-H club member currently in high school grade level 11 or 12.
I am an active 4-H club member of a chartered club.
I submitted a recordbook in June 2013 and will submit a recordbook in June 2014.
No SAT or ACT scores are required.
I understand that I must attend an interview in person on June 24.
Applicant Signature: ____________________________________________________________ Date: __________________
Parent Signature: ______________________________________________________________ Date: __________________
Applicants for the Mark Green Scholarship:
Please Read Eligibility Requirements and Certify:






I am a Tarrant County 4-H club member who is a graduating Senior.
I am an active member of a chartered club, having attended at least 50% of club meetings.
I have been active in 4-H for the past four (4) years.
I submitted a recordbook in June 2013 and will submit a recordbook in June 2014.
No SAT or ACT scores are required.
I understand that I must attend an interview in person on June 24.
Applicant Signature: ____________________________________________________________ Date: __________________
Parent Signature: ______________________________________________________________ Date: __________________
I verify that the applicant has attended at least 50% of club meetings and has been active for the past four (4) years.
Club Manager: _______________________________________________________________
Date: _________________