Student name: _________________________________________________
Home Address: _________________________________________________
__________________________________________________
__________________________________________________
Home phone: ___________________
School currently attending: _____________________________________
Phone: __________________ Contact: ______________________
School to receive scholarship: ___________________________________
Address: _________________________________________________
__________________________________________________
Phone: _________________ Contact: ______________________
Event covered: ________________________________________________
Event date: ____________________________
Location: __________________________________________________
Sponsoring club: ______________________________________________
Contact: ____________________________ Phone: __________________
Date submitted: __________________
Comments: _____________________________________________________
******************* for official use only *********************
DATE REC'D:___________________
PUBLISHED:_____yes _____no PUBLISHED DATE:___________________
JUDGES SCORE:
1:____ 2:____ 3:____ 4:____ 5:____ TOTAL:___________