KMBC Scholar Athlete Nomination Form

The KMBC-TV / Hy-Vee Scholar Athlete Scholarships are for high school seniors graduating in the spring of 2019 who excel athletically and academically in high school. High school seniors must attend a school in the KMBC-TV viewing area. Each high school may nominate a total of five students for this Scholarship. The KMBC-TV/Hy-Vee Scholar Athlete Nomination Form should be completed ONLY by students nominated by a high school administrator. School Districts in Kansas and Missouri eligible to nominate students have received a letter requesting nominations. If you have not been nominated or if you do not attend a school in the KMBC-TV viewing area you are not eligible to submit a nomination.

PLEASE NOTE: THIS FORM MUST BE COMPLETED AND SUBMITTED ALL AT ONE TIME. DATA ENTERED CANNOT BE SAVED IF THE WINDOW OF THIS FORM IS CLOSED.

THE DEADLINE TO SUBMIT THIS NOMINATION IS TUESDAY, JAN. 15, 2019

1. School District And School Information

School District State (Kan. or Mo.) *This question is required.

School District Name *This question is required.

School District County *This question is required.

School Name *This question is required.

School Address *This question is required.

School Phone Number *This question is required.

School Scholarship Contact Name *This question is required.

School Contact Email Address *This question is required.

School Contact Phone Number *This question is required.

State

Postal Code

Country

Phone Number

Fax Number

Mobile Phone

Website

2. Student Contact Information *This question is required.

Student First Name *This question is required.

Student Last Name *This question is required.

Title

Company Name

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Country

Student Email Address *This question is required. This question requires a valid email address.

Student Home Number *This question is required.

Student Cell Number

Mobile Phone

URL

3. Student Nomination Information *This question is required.

Student GPA *This question is required.

List Student Sports *This question is required.

List All Academic Accomplishments *This question is required.

List All Athletic Accomplishments *This question is required.

List all extracurricular activities, awards including school and civic organizations *This question is required.

4. EDUCATOR NOMINATION STATEMENT: The nomination statement should be written by a school teacher, coach or counselor. The statement should include comments about the student and why he/she is deserving of a Scholar Athlete Scholarship.

Educator Name *This question is required.

Educator Title *This question is required.

Educator School Email Address *This question is required.

Educator School Phone Number *This question is required.

5. Please attach the educator nomination statement (include student's first and last name in statement) and any additional support documents you'd like to include. *This question is required.

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