Northern Arizona University s5

DUSTIN AND KRISTEN YODER MEMORIAL FOUNDATION, INC. SCHOLARSHIP APPLICATION

**** APPLICATION DEADLINE: March 15th, 2013****

Download this form to your computer and save it as a document, then type your answers in the fields provided. You may need to click "enable editing" if a box appears at the top with "Protected view". Advance to each subsequent field by using your tab key or clicking on each new box with your mouse. Answer as thoroughly as possible. If an item does not apply to you, put "N/A" in the field. Your essay should be clearly written but succinct. If submitting by email, your completed application must have your digital signature and that of your parents or guardians if you are under age 18. If delivering or mailing, your completed application must have handwritten signatures. Applications without necessary digital or handwritten signatures will not be accepted or considered. Save the application with your answers once you have completed the application. To submit your application, email it prior to the application deadline stated above to BOTH of the following: [email protected] (Nicole Harris ----Administrative Assistant at the Department of Geography Planning and Recreation at NAU) and [email protected] (Ken Yoder---- President of Dustin and Kristen Yoder Memorial Foundation, Inc.) You may also print your application and return it in person to Nicole Harris at the Geography, Planning and Recreation office, Room 201, SBS West (building 70) and by mail to Ken Yoder, 5634 Gebert Road, Muldoon, Texas 78949.

PERSONAL INFORMATION

Applicant's Name Last First MI

Phone - -

Mailing Addresses:

Permanent Number, Street, Apt. No. (if any), City, State and Zip Code

Local Number, Street, Apt. No. (if any), City, State and Zip Code

Sex M F Date of Birth / / Email M D Year Citizenship (country) Country where you were born

Marital Status Single Married Divorced Separated

ACADEMIC ACHIEVEMENT Approximate number of credits left to graduate (after this semester)

Expected College Graduation Date / (month/year) College Major

College Minor or Merged Major

Estimate the number of hours you will be taking next fall and next spring

Cumulative NAU GPA Number of NAU Credits Major (Department) GPA

Provide an academic summary of your last four (if possible) semesters of full-time enrollment. This academic history could be from NAU, another 4-year college or university, a community or junior college, or any combination of these. Grade points are calculated by giving an ‘A’ 4 grade points for each credit; a ‘B’, 3 grade points; a ‘C’, 2 grade points; and a ‘D’, 1 grade point. The GPA is then the total grade points divided by the total credits.

Institution’s Name Semester and Number of Credits Semester GPA Year Earned

FINANCIAL INFORMATION

Dependency Status: Dependent for Tax Purposes % Self-Supporting (approximate) Not a Dependent for Tax Purposes

Do you have any other scholarships for the coming year? yes no. If so, list in the field below.

Significant or pertinent jobs over the last several years:

Start Date: / Termination Date: / Month/Year Month/Year

Name of employer (address, phone number, contact person if known)

Description of Job

How do you plan to finance the rest of your education (loans, scholarships, grants, employment, work- study, etc.)?

AWARDS AND ACTIVITIES

List in reverse chronological order (most recent to least recent) in the field below high school or college clubs and organizations with which you have been involved. Include honors, awards, offices held, responsibilities taken on, etc.

List in the field below any other outdoor activities, leadership programs, or courses you have taken or in which you participated. 3

In the field below, please explain why this scholarship is important to continue your education. Include comments on your career goals and how you plan to use your outdoor leadership training upon graduation. Your application will in part be judged on the quality and content of your written statement. This field is limited to 3000 characters, so please be succinct.

ADDITIONAL INFORMATION (not required but may be helpful)

Briefly comment on other factors or information about you, your family, or your financial situation that the Scholarship Committee ought to consider that may be helpful in reaching its decision. This field is limited to 1000 characters.

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 Northern Arizona University will provide the Foundation with a report of my successful completion of the course or program. I understand that I am responsible for gaining admission to the N.A.U. Outdoor Leadership Program, for all costs associated with such course or program, and that a scholarship award may only be for a portion of the course or program listed above. Once the Foundation has awarded a scholarship, 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; (f) providing any false or misleading information on this application or any other information provided to 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 hereby consent to release of my academic, financial, and/or any other information as required by NAU or by the Foundation.

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 safety in any outdoor education or leadership course or program in which I choose to participate, and are not responsible for enabling me to pursue my studies. The Dustin and Kristen Yoder Memorial Foundation, Inc., its directors, officers, representatives and agents assume no responsibility, liability or obligation whatsoever beyond providing the monetary scholarship award.

4 Date: / / Signature of Applicant Month/Day/Year (type in signature and date if emailing application; handwrite signature and date if delivering and mailing application)

Date: / / Signature of parent or guardian (if applicant under 18) Month/Day/Year (type in signature and date if emailing application; handwrite signature and date if delivering and mailing application)

If you submit your application by email, then typing your name(s) in the spaces above constitutes your digital signature and your agreement to submit this application by electronic means and our agreement to accept delivery of and to consider your application by electronic means, as described in Arizona Revised Statutes Section 44-7001 et seq. Your electronic signature has the same legal effect as your handwritten signature. You represent and warrant that the electronic signature above is the act of the person whose name appears in the signature space. If you print your application and submit it by mail, then you must sign your name(s) and date in the space provided above.