Grundy County Farm Bureau Foundation High School Scholarship Application Deadline for submittal: March 31, 2017 Must be typed.

Part I: General Information 1. Name: Last

First

Middle Initial

2. Home Address: Street or RR

City

State

3. Telephone Number: 4. Email Address: 5. Grundy County Farm Bureau Membership Number: 6. High School:

Date of Graduation:

7. Father’s Name in full: 8. Mother’s Name in full:

Part II: Academic Information 1. GPA (OFFICIAL TRANSCRIPT)

Class Rank

/

2. ACT or SAT Score: 3. What academic awards/honors have you received?

Part III: Activities 1. List the student activities in which you participate. Indicate offices and positions of leadership held, as well as honors received. Include all extracurricular activities.

Zip

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2. List community activities and year. Indicate offices and leadership positions held, as well as honors received.

3. Describe any employment experiences.

Part IV: Interests 1. Summarize your experience and interest in agriculture/agribusiness.

2. What hobbies or special interests do you have?

Part V: Academic Plans 1. Name of junior college, college, university, or vocational school you plan to attend:

2. Briefly state your major field of study:

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3. Describe how you think your course of study will benefit the field of agriculture.

4. Why do you feel you should be awarded a Grundy County Farm Bureau Foundation Scholarship?

Party VI: Financial Analysis Report Since financial need is one factor in selecting the recipient of the Grundy County Farm Bureau Foundation Scholarship, the following information will help the Scholarship Review Committee in its deliberations. The information is strictly confidential and will only be reviewed by the Foundation’s Scholarship Review Committee. 1. Will you work during the school year to support your education? If so, approximate: Hrs/week: Income: Where: Type of work: 2. Do you intend to work during the summer? Hrs/week: Income: Where: Type of work: 3. A. Will you receive a tuition waiver? If so, please indicate the name and value of the waiver. 3B. Are you receiving a scholarship(s)? Name of Scholarship 1. 2. 3. Page 3 of 5

Value

4. Approximate amount in: Savings Checking 5. Do you have debt?

Cash

If so, detail amount and description:

6. Approximate percentage of parental support for you education: 7. Father’s occupation: 8. Mother’s occupation: 9. Number of children in family: 10. Number of children in higher education: 11. Do you reside with your parents?

If not, with whom?

Signature: ____________________________________ Date: ______________

A completed application consists of the following:  A completed typed application  Official High School Transcript  Teacher Recommendation  Character Recommendation  Essay of 300 words or less answering the question, “What are your interests and goals and how are they related to your future in the ag industry or rural communities?”

The recommendations should be submitted by you with the rest of the application. You should request that person filling out the application form; return it to you in a sealed envelope. Please do not submit this application until it is complete. The Foundation Board reserves the right to ask an applicant for an interview. DEADLINE: Please return or mail application to the Grundy County Farm Bureau, 4000 N. Division, Morris, IL 60450. Application must be received by 4:00 PM March 31, 2017

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AUTHORIZATION AND RELEASE: I understand that should I be selected a scholarship winner as a result of submission of this application, I will be asked to submit a photograph for Grundy County Farm Bureau Foundation’s publicity purposes. I hereby authorize the Grundy County Farm Bureau to publish my picture in the event that I am selected a winner and expressly release Grundy County Farm Bureau, its officers, employees, and ages from any and all claims, known or unknown, rising out of or in any way connected with the uses described above. (NOTE: If the applicant is under 18, a parent must sign.)

Signature_________________________________________________ Print Name________________________________________________ Parent Signature (if under 18) _________________________________ Date______________

Upon completion, please return all forms in a 9x12 sealed manila envelope.

Thank you!