Application for 4-H Activity Scholarship
Our office receives a limited amount of money to help 4-H’ers with registration payments for 4-H events. Please complete the information below and return to the Moultrie-Douglas Extension Office in order to be considered for a 4-H Scholarship during the current 4-H year. Dollar amount of scholarship will be determined once all applications for event are reviewed.
Name ______
Age ______
Address ______
City ______Zip ______
Member of ______4-H Club
Name of Camp, Conference, Workshop you wish to attend: ______
Date of event: ______Registration Deadline: ______
Have you attended this event before? ______If so, how many times? ______
Do you have any siblings attending, if so, how many? ______
Number of 4-H Club meetings you have attended this program year (since Sept 1) ______
Besides club meetings, please list other club and/or county 4-H activities you attended this 4-H year? ______
In the member’s own handwriting, please tell us why you are interested in attending this event, what you hope to learn and how you will share what you have learned with others.
______Over______
I acknowledge that I am currently enrolled as a Moultrie-Douglas 4-H member.
Member Signature Date
I, as parent or legal guardian of the 4-H member named above, understand that the scholarship will be given when the 4-H member has attended the activity listed on this application.
Parent/Guardian Signature Date
Return this scholarship application form at least one month
prior to the event you would like to attend to:
University of Illinois Extension
Moultrie Douglas Unit
122 S Walnut
Arthur, IL 61911
(217)543-3755
4-H’ers selected to receive scholarship money will be notified prior to their attendance.
After you have attended the event, scholarship money will be issued, unless prior arrangements have been made.
Submission of this scholarship application does not guarantee you a scholarship.
FOR OFFICE USE ONLY
______
4-H Extension Staff Signature Amount Awarded Date Issued