KMBC 9 Scholar Athlete Nomination Form

The KMBC-TV / Hy-Vee Scholar Athlete Scholarships are for high school seniors graduating in the Spring of 2022 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 MONDAY, JANUARY 10, 2022.

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* 1. School Information

School Name *

School District *

School Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

School Scholarship Contact Name

School Scholarship Email *

School Scholarship Phone Number *

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* 2. Student Contact Information

Student First Name *

Student Last Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Student Email Address

Student Cell Number *

Student Home Number *

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* 3. Student GPA

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* 4. List all academic accomplishments

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* 5. What high school sports does the student play?

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* 6. List athletic accomplishments

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

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* 8. 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 the Scholar Athlete Scholarship.

Educator Name

Educator Title

Educator School Email Address

Educator School Phone Number

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* 9. 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.

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