SCHOLARSHIP APPLICATION



SCHOLARSHIP APPLICATION

DUSTIN AND KRISTEN YODER MEMORIAL FOUNDATION, INC.

Please complete all the information requested below. All applications must be typed. Applications not typed will not be accepted. Applications must be submitted no later than APRIL 20, 2008.

PERSONAL INFORMATION:

Applicant Name:

Address:

Telephone Number: (home)

(cell)

(other)

E-mail address:

Date of Birth:

Age:

Male: Female:

Country of citizenship:

Country of birth:

Current Grade or Class:

Past schools you have attended (use separate sheet of paper if necessary):

Name of school enrolled in or applying to:

School Address:

Name of Outdoor Education Course or Program to which scholarship will apply:

Expected graduation date:

Date(s) of Course or Program to which scholarship will apply:

Description of Course or Program to which scholarship will apply:

Cost of Course or Program: $

Explain how this course or program furthers your outdoor educational goals (use separate sheet of paper if necessary):

List other outdoor education or outdoor leadership education courses and/or programs you have taken or in which you have participated (use separate sheet of paper if necessary):

List extra-curricular activities, honors and awards (use separate sheet of paper if necessary):

List any employment you have had (use separate sheet of paper if necessary):

What is your career objective (use separate sheet of paper if necessary)?

How did you find out about the Dustin and Kristen Yoder Memorial Foundation Scholarship?

Please provide a copy of your most recent transcript from an educational institution.

FINANCIAL STATUS:

Names and ages of other dependent children in the family (not including applicant):

How do you plan to finance your education (loans, scholarships, grants, employment, work-study)?

What percentage of your educational costs are provided by your parents?

Have you received a scholarship from the Foundation before? Yes No

If so, when and what amount?

PERSONAL STATEMENT:

On a separate paper, please provide a personal statement addressing any other information about you, your family, your financial needs for your education, your goals, or your career ambitions and how the course or program listed above will help you reach your goals and ambitions, and any other information that you think may be helpful to the Foundation in reaching its decision.

CERTIFICATION AND AGREEMENT:

I am hereby applying for a scholarship from the Dustin and Kristen Yoder Memorial Foundation, Inc. I certify that the above information is true, accurate, correct and complete to the best of my knowledge. If I receive a scholarship award from the Foundation, I agree to participate in and complete the outdoor education or outdoor leadership course or program set forth in this application and I acknowledge that upon completion of the course or program, I will be required to provide to the Foundation a written statement of the value of the course or program to me and my plans for continued outdoor education. I also understand that the educational institution set forth above will provide the Foundation with a report of my completion of the successful course or program. I understand that I am responsible for gaining admission to the school, course or program listed above, for all costs associated with such course or program, and that a scholarship award will be only for the course or program listed above. Once a scholarship has been awarded by the Foundation, I cannot change the course or program without the express written consent of the Foundation and the educational institution. I understand that a scholarship may be revoked for any of the following reasons: (a) withdrawal from or failure to complete the course or program listed above; (b) inability to secure admission or enrollment to the course or program listed above; (c) evidence of misconduct; (d) failure to submit reports as required; (e) changing courses or programs without the prior written consent of the Foundation. I understand that revocation of a scholarship shall cause all payments to cease and may make me liable for return of payments previously provided.

I understand and agree that the Dustin and Kristen Yoder Memorial Foundation, Inc., its directors, officers, representatives and agents are in no way liable for my personal welfare or responsible for enabling me to pursue my studies beyond the period of the scholarship or the amount of the scholarship. The Dustin and Kristen Yoder Memorial Foundation, Inc., its directors, officers, representatives and agents assume no responsibility, liability or obligation whatsoever beyond providing the amount of the scholarship as stated herein.

Date:

Signature of Applicant

Print Name of Applicant Signature of parent or guardian (if applicant under 18)

Print Name of Parent or Guardian

Send your completed application and all requested supplemental information to:

Dustin and Kristen Yoder Memorial Foundation, Inc. Scholarship

c/o Law Office of David K. Gray, P.C.

4500 N. Avenida Polacca

Tucson, AZ 85749

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