0524-NEW National 4-H Conference Scholarship Form

OMB Number 0524-XXXX

Expiration Date XX/XX/XXXX

NATIONAL 4-H CONFERENCE SCHOLARSHIP FORM
To be considered for the National 4-H Conference Scholarship Program, please follow the steps listed below. STEP 1: Applicants must complete Part A (saved as LastName-FirstName_ScholarshipForm_Natl4-HConf) with resume (saved as LastName-FirstName_Resume_Natl4-HConf). STEP 2: Email the completed form with resume to your Land-grant University or State 4-H Office using subject line “National 4-H Conference Scholarship Program”. STEP 3: The Land-grant University or State 4-H Office must email completed forms and resumes to National4-HConference@usda.gov, using subject line “National 4-H Conference Scholarship Program” by scholarship deadline. STEP 4: If selected as a scholarship recipient, complete Part B and email the completed form to your Land-grant University or State 4-H Office using subject line “National 4-H Conference Scholarship Program Recipient”.
PART A – SCHOLARSHIP INFORMATION
APPLICANT INFORMATION (Required) List the following information found on your photo identification.
FULL NAME (First, Last)		DATE OF BIRTH (Month Day Year)
MAILING ADDRESS		Apt, Unit, etc.
CITY	STATE	ZIP CODE
EMAIL ADDRESS		CELL PHONE NUMBER
REGISTRATION TYPE (Select one) ☐ Adult Chaperone ☐ Youth Participant (Delegate)
DEMOGRAPHIC INFORMATION (Optional) This information will inform our understanding of diversity and inclusion among the National 4-H Conference scholarship recipients.
AGE (on 1st day of National 4-H Conference) Youth delegates must be 15 to 19 years-old.		GRADE LEVEL
ETHNICITY (Select one) ☐ Hispanic or Latino ☐ Not Hispanic or Latino ☐ I prefer not to share	RACE (Select one or more) ☐ American Indian or Alaskan Native ☐ Asian ☐ Black or African American ☐ Native Hawaiian or Other Pacific Islander ☐ White ☐ I prefer not to share	GENDER ☐ Female ☐ Male ☐ Non-binary ☐ I prefer not to share
4-H PROGRAM INFORMATION
How many years have you participated in 4-H? ☐ Less than 1 year ☐ 2 to 5 years ☐ 5 to 10 years ☐ More than 10 years
Which Land-grant University is your 4-H program associated with?
Have you previously attended National 4-H Conference? ☐ Yes ☐ No If yes, what year?
REFERENCES Please enter the name, phone, and email address for two references, who are not related to you.
REFERENCE FULL NAME (First, Last)		RELATIONSHIP
TELEPHONE NUMBER		EMAIL ADDRESS
REFERENCE FULL NAME (First, Last)		RELATIONSHIP
TELEPHONE NUMBER		EMAIL ADDRESS
QUESTIONNAIRE (Youth Participant Only) Please write a clear and complete response to each question. These questions are an opportunity to introduce yourself and explain why you would like to attend National 4-H Conference.
Why are you interested in attending National 4-H Conference? (100 words)
What do you hope to gain from this experience? (100 words)
At the National 4-H Conference, federal agencies will ask for youth voices to help solve complex issues affecting their agencies. What unique perspective would you bring to the conference? (100 words)
How have you demonstrated civic engagement (volunteering to help others) in your community? Include community service projects, civic engagement programs or activities you have participated in. (100 words)
Please send a PDF of your current resume outlining your education and experience relevant to leadership and civic engagement. Name the file as LastName-FirstName_Resume_Natl4-HConf.
PARTICIPANT AFFIRMATION
☐ By checking the box to the left, I affirm that all the information included in this application about my personal information, background, experiences and skills is accurate. I am either 18 years of age or older, or I have discussed this with my parents/legal guardian, who by their signature below agree with my decision to attend National 4-H Conference. ☐ By checking the box to the left, I consent to receive email, mail, texts or phone call communications relating to announcements, assignments, logistics, mentoring or similar matters regarding the National 4-H Conference.
PARTICIPANT NAME (First, Last)	PARTICIPANT SIGNATURE	DATE
PARENT/GUARDIAN CONSENT
☐ By checking the box to the left, I affirm that I am the parent/guardian of the abovenamed participant and consent to their participation in the National 4-H Conference scholarship opportunity. I understand that providing consent is voluntary and not required. I understand that not providing consent may limit this young person’s ability to receive a National 4-H Conference scholarship.
PARENT/GUARDIAN NAME	PARENT/GUARDIAN SIGNATURE	DATE
EMAIL		TELEPHONE NUMBER
PART B – REGISTRATION INFORMATION Complete Part B only if selected as a scholarship recipient. Part B includes the additional information collected on the National 4-H Conference online registration system.
PARTICIPANT INFORMATION
T-SHIRT SIZE ☐ Small ☐ Medium ☐ Large ☐ XL ☐ 2XL ☐ 3XL
LODGING INFORMATION (Required) This information must be assigned by Land-grant College or University or Military Service Branch.
CHECK-IN DATE		CHECK-OUT DATE
NAME OF ROOMMATE
REASONABLE ACCOMMODATIONS
ACCOMMODATION REQUESTED (be as specific as possible, if accommodation is time sensitive, please explain)
REASON FOR REQUEST
DIETARY INFORMATION
DIETARY RESTRICTIONS (check all boxes that apply) ☐ None ☐ Dairy Free ☐ Vegan ☐ Nut Free ☐ Gluten Free ☐ Vegetarian ☐ Other________
NAME BADGE INFORMATION
List your first name as you would like it to appear on your name badge.
List the Land-grant Institution or Military Service Branch you are representing. Examples: Purdue University, Indiana; Virginia State University, Virginia; Hill Air Force Base, Utah; USAG Brussels Army Base, Belgium
☐CTIVITY PREFERENCES
List your top three choices for challenge question topics. Challenge question topics can be found in the Delegate Handbook. (For Youth Delegates Only) 1st choice 2nd choice 3rd choice
List your delegates top three choices for community service. Community Service choices can be found in the Delegate Handbook. (For Chaperones Only) 1st choice 2nd choice 3rd choice
How many people (adult chaperones and youth delegates) are in your delegation? (For Chaperones Only)
QUESTION FOR THE U.S. SECRETARY OF AGRICULTURE (Optional)
If you had the chance to ask the U.S. Secretary of Agriculture a question, what would it be?
PARTICIPANT AFFIRMATION
☐ By checking the box to the left, I understand my behavior affects the entire National 4-H Conference community and that I represent myself, my local and state/territory 4-H Program and the 4-H Youth Development Program. Therefore, I have read, understand, and will abide by the National 4-H Conference Handbook and Code of Conduct. ☐ By checking the box to the left, I consent to the reproduction, and use, royalty-free, of motion picture films, videotapes, recorded sounds, and still photographs of me by the Communications Staff, National Institute of Food and Agriculture, United States Department of Agriculture for all purposes including, but not limited to, education, training, trade, display, editorial, advertising, promotion, art, and exhibits. In giving this consent, I release the United States, its officers, employees, nominees, and designees from liability for any violation of any personal or proprietary right I may have in connection with such reproduction, and use. ☐ By checking the box to the left, I understand that all publications, films, slides, videos, artistic or similar endeavors, resulting from my National 4-H Conference experience will become the property of the United States, and as such, will be in the public domain and not subject to copyright laws. ☐ By checking the box to the left, I consent to receive email, mail, texts, or phone call communications relating to announcements, assignments, logistics, mentoring, or similar matters regarding the National 4-H Conference. ☐ By checking the box to the left, I consent to participate in National 4-H Conference evaluation by a third-party evaluator. Evaluation may include participating in observations, evaluations, and feedback relating to a participation in National 4-H Conference activities (such as survey assessments or formal observations). I consent to share my demographic information (such as age, ethnicity, race, gender identity, Land-grant University, etc.) with the third party National 4-H Conference evaluator. ☐ By checking the box to the left, I consent to be transported while participating in and traveling to and from this event by hired drivers authorized by the organizers of National 4-H Conference.
PARTICIPANT NAME (First, Last)	PARTICIPANT SIGNATURE	DATE
PARENT/GUARDIAN CONSENT
☐ By checking the box to the left, I affirm that I am the parent/guardian of the above-named participant and consent to their participation in National 4-H Conference. I have read, understand, and agree to follow the National 4-H Conference Handbook and provide consent for the participant affirmation(s) checked above. I understand that providing consent is voluntary and not required. I understand that not providing consent may limit this young person’s ability to participate in National 4-H Conference.
PARENT/GUARDIAN NAME
EMAIL		TELEPHONE NUMBER
PARENT/GUARDIAN SIGNATURE		DATE
NON-DISCRIMINATION STATEMENT
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender. Public reporting for collection of information is estimated to average 1 hour, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIFA, OGFM, 2312 East Bannister Road, Mail Stop 10,000, Kansas City, MO 64131, Attention Policy Section. Do not return the completed form to this address. National Institute of Food and Agriculture US Department of Agriculture OMB No. 0524-NEW Form Approved For Use Through xx/xx/xxxx

National 4-H Conference Scholarship Form

USDA is an equal opportunity provider, employer, and lender.