2010 4-H State Leadership Conference
Financial Assistance Information
Due postmarked May 15, 2010
Revised 2-3-2010
Through gifts secured by The California 4-H Foundation, the State 4-H Office is able to
provide financial assistance which will allow youth to attend the 2009 4-H State
Leadership Conference, July 29- August 1, 2010 at UC Davis
Financial assistance will be allotted on an “as needed and available” basis and is not
transferable. Delegates may request up to $330 of financial aid. Financial aid selections
are based on:
? Income of the family and family size
? Contribution to the diversity of the 4-H State Leadership Conference (e.g. participation in different delivery modes, those requiring special needs, etc.)
? Extenuating circumstances such as the death of a parent, parental unemployment, etc.
? Preference to those not having received financial aid previously
? Those demonstrating an active interest in developing and utilizing skills learned after the conference
? Expected transportation costs to the campus hosting the conference based on geographic distance
Upon returning from the conference, all youth receiving financial aid must complete the following:
? Write a letter of thanks to the Wells Fargo Foundation. County 4-H Staff will collect these letters and mail them to
the State 4-H Office in one envelope. Individual postage for each letter will not be necessary.
? Include a brief summary describing how the conference experience impacted the delegate and what actions were taken
after the conference. This will be used to compile a post-conference report to Wells Fargo outlining how their gift
was utilized, and will help to ensure future donations by Wells Fargo.
Counties who do not send thank-you letters for each delegate that received funding will receive a bill requesting payment of
the remaining registration fees.
Incomplete applications will not be considered. Complete applications must consist of both pages of the application. Counties
will receive notification of funding by May 29. Please mark “Confidential” and fax or mail to:
Quang “Hogan” Tong
State 4-H Office 530-752-5644
UC Davis qtong@ucdavis.edu
DANR Building, One Shields Ave
Davis, CA 95616-8575
We offer our sincere thanks for Wells Fargo’s long-standing support of the 4-H State Leadership Conference that has allowed the State 4-H Office to offer financial aid to youth delegates since 1994. In addition, we wish to thank
The California 4-H Foundation for its work in securing Wells Fargo’s support.
County: __________________________________________________________
Name: ___________________________________________________________
Age: _____________ Grade: ____________ Gender: ? Male ? Female
Address: _________________________________________________________
City: ____________________________________ Zip: _______________
Telephone: _______________________________________________________
4-H Enrollment Status (check all that apply):
? Club ? Special Interest/Short-Term ? Overnight Camping ? Military 4-H ? School Enrichment ? Individual Study ? School-aged Child Care
Ethnicity (check one that applies best):
? White ? Black/African American ? Hispanic/Latino ? Asian/Pacific Islander ? American Indian/Alaskan Native ? Multi-Ethnic
Place of Residence (check one that applies best):
? Farm ? Rural-Non Farm (under 10,000) ? Town (10,000-50,000)
? Suburb of City (over 50,000) ? City (over 50,000)
Mark years of previous financial aid/scholarships you have received:
? None ? 2009 ? 2008 ? 2007 ? 2006 ? 2005 ? 2004
Amount Requested: $_________ ($330 maximum)
Please answer the questions below on an additional piece of paper.
1. Why are you interested in attending this conference?
2. What do you hope to accomplish after the conference with the information you will have learned?
As part of your attendance at this conference, you are required to send a thank-you letter to the Wells Fargo Foundation after
you return. By signing below you agree to this commitment and the accuracy of the information provided.
Signature of Applicant: __________________________________________________ Date: ____________
I verify that this individual is enrolled as a 4-H member in my county.
Print Name: ___________________________________________________________________________
Signature of 4-H Staff: __________________________________________________ Date: ____________
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These questions will be used in selecting youth to receive financial assistance for the 2009 4-H State Leadership Conference.
Applicant’s Name: ________________________________County: _______________________________
Our annual family income is:
? Below $15,000 ? $15,000 to $30,000 ? $30,000 to $40,000 ? $40,000 to $50,000
? $50,000 to $60,000 ? $60,000 to $70,000 ? $70,000 to $80,000 ? $80,000 and above
Our family is: ? A single-parent household ? A two-parent household
The number of dependents in the house _____________________
Please mark all that apply:
? Temporary Assistance to Needy Families (TANF)
? Food Stamp Program
? Section 8 Housing
? Attendance at a Chapter I School and a school where 50% of the youth receive free lunches
? Free school lunch and/or breakfast program
? MediCal Card
? Foster Care or Group Home
? Neighborhood Youth Corp (NYC)
? Summer Youth Training Employment Program (SYTEP)
? MESA - minority low-income math and science education
? California Conservation Corps
? Family member in Head Start
? Other: __________________________________________________________________
Please add any additional comments and explain any extenuating circumstances.
By signing, I confirm the accuracy of the information provided.
Signature of Applicant: __________________________________________________ Date: ____________
Signature of Parent/Guardian: ______________________________________________Date: ____________
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