Qualtrics Survey | Qualtrics Experience Management

Full Legal Name (as it appears on your ID):

Date of Birth (mm/dd/yyyy):

Age at time of national event:

Years in 4-H:

Cell Phone (xxx-xxx-xxxx):

E-mail:

Address:

City:

State:

Zip Code:

County:

Please list and/or describe your major 4-H projects and accomplishments especially those that relate to leadership and civic engagement:

Please describe in detail what you hope to learn as a result of going on the national civic engagement trip:

4-H Member Signature and Date:

Sign Here

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Parent/Guardian Signature and Date:

Sign Here

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Your Susan K. Dufner Scholarship application will be forwarded to your county agent for signature.
Thank you for your application!