Name:________________________________________________
Address:______________________________________________
Phone:___________________Birthdate:____________________
Parents/Legal Guardian:________________________________
Email:________________________________________________
Years in 4-H:______________Club:_______________________
Post Secondary Institution you are planning to attend:
_____________________________________________________
Signature of 4-H Member:_______________________________
Signature of Parent/Guardian:___________________________
1. What are your post secondary education plans?
Return application and letters of recommendation to the CEO by May 15, 2015.

2.
How would this scholarship impact your pursuit of a post secondary education?
3. Please describe your 4-H involvement at the local club, county, and state levels.
Return application and letters of recommendation to the CEO by May 15, 2015.

4. Describe your leadership roles, achievements, etc.
5. What have you personally given to the 4-H Program?
Return application and letters of recommendation to the CEO by May 15, 2015.

6. How have you personally benefited from the 4-H Program?
7. How has 4-H helped you plan for your future?
Return application and letters of recommendation to the CEO by May 15, 2015.