BUTLER COUNTY SPECIAL AWARD APPLICATION

This application form is to be completed for the following special awards: “I Dare You” Award, Kiwanis 4-H Junior Leader Award, Service to 4-H and Community Award and Dr. Johnson Outstanding 4-Her Award.  A 4-H member must be 14 years of age as of January 1 of the current year to apply for special awards.  A letter of recommendation from a non-related 4-H Volunteer Leader must be attached to the completed form. Complete this form for all years in 4-H, not just current.

Name: ________________              Age:                         Phone: ________________ 	

Address: ________________          City: _________           Zip Code: ___________

Years of 4-H Completed:      

School:       	Grade in School:      

Requirements: Mark each item once you have completed the task.

•	I have attached a letter of recommendation.
•	I am 14 years of age as of January 1st of the current 4-H years
•	I have marked the award for which I am applying
•	I have noted the year in which I have received previous awards (If applicable)
•	Application has been signed by a parent or guardian
•	I will participate in the interview on the scheduled date and time

Mark the award you are applying for with an X. Mark any award that you have previously received with the year that you received the award.

“I Dare You”       	Kiwanis 4-H Junior Leader       

Service to 4-H and Community       	Dr. Johnson Outstanding 4-Her       

4-H INVOLVEMENT

1.  Major projects:

     

2.  Summarize major 4-H leadership given to local club (L), county (C), and state (S).  Designate with letter.

     

3.  Summarize major 4-H achievements and recognition (do not include specials awards listed above).

     

4.  List major 4-H events attended or participated in.

     

SERVICE AND LEADERSHIP GIVEN TO OTHERS
1.  School
     

2.  Community
     

3.  Church
     

MY FUTURE GOALS ARE:

     

I have personally prepared this application and believe it to be correct:

Signature of applicant______________________________________________________ Date____________

Approval of this application is given by:

Signature of parent________________________________________________________ Date____________

K-State Research and Extension - Butler County                                                                                                                 January 2019
All educational programs and materials are available without discrimination on the basis of race, color, national origin, sex, age, or disability.

                                                                                                                                                                 Revised January 2019