The Benevolent and Protective Order of Elks

NOMINATION FORM TEENAGER OF THE YEAR SPONSORED BY THE BENEVOLENT AND PROTECTIVE ORDER OF ELKS KENTON LODGE #157

Nominee’s Full Name ______Last First Middle Parent’s Names ______

Address ______

Home Phone _____ Date of Birth ______

I give my permission for the release of the information given on this form to members of the Kenton Lodge Scholarship Committee and to the news media for the purpose of evaluating scholarship candidates and recognition of the student and the Elk’s scholarship program.

______Student Signature Parent Signature

PLEASE COMPLETE THE FOLLOWING SECTIONS OF THE FORM AND SUBMIT IT ALONG WITH THREE (3) LETTERS OF RECOMMENDATION. ONE (1) LETTER MUST BE FROM THE SCHOOL’S GUIDANCE COUNSELOR OR PRINCIPAL AND THE OTHER TWO (2) CAN BE FROM SOMEONE OF THE NOMINEE’S CHOICE.

EDUCATION

High School Attended _____Hardin Northern _____

Expected Date of Graduation ______

Cumulative Grade Point Average ______

Academic Honors Received:

WORK EXPERINCES List and explain any work experiences of the nominee, including full time employment, part-time work, summer jobs, etc., whether paid or unpaid. Give years these positions were held. FUTURE PLANS Briefly explain your future plans regarding education and career expectations and goals.

ACTIVITIES AND ACHIEVEMENTS

SCHOOL INVOLVEMENT List all school activities (academic, athletic, service, social) in which the nominee has participated. Please indicate the year(s) of participation with the (9, 10, 11, 12) designation, and note any awards or recognition.

NON-SCHOOL INVOLVEMENT List all non-school activities (club, service, social) in which the nominee has participated. Please indicate the number of years of participation with the (2yrs., 6yrs.) designation, and note any awards or recognition received. LEADERSHIP ROLES List any offices held in any school or non-school activities in which the nominee has participated. Please indicate the years in which the office was held.

PHILOSOPHY Briefly give your beliefs about our American society and your role in it.

COMMUNITY SERVICE List and briefly explain volunteer work provided by the nominee for the good of the community as a whole or for individuals within the community. Give years these services were provided.