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Citizen Scholar Nomination Form

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Complete the form below. You should receive a confirmation email within 20 minutes.
Field validation - color of fields will indicate:
General Information
School Name:
Candidate Name:
Birth Date:
(m/d/yyyy)
Home Address:
Home Telephone #:
(With area code, no dashes, dots, or slashes)

Parent(s)/Guardian(s) Names(s) and Place(s) of Residence:
Projected 4-year GPA:
Class Rank:
(if known)

Questionnaire

Please answer the following questions.


School-Sponsored Activities:
(list years involved, offices held)

Civic/Church/Volunteer Activities:
Favorite School/Civic/Church/Volunteer Activity:
(from those listed above)

School Year/Summer Jobs:

Future Plans (College/Career/Etc.)

How did you manage to keep your grades up while being so active in school and community?

Why did you choose to be so active in your school and community?

Describe your most meaningful achievement in high school. How was it meaningful?

How have you demonstrated leadership abilily both in and out of school?

What was your most difficult time in high school? How did your perspective on life change as a result of the difficulty?

Photo Submission
How would you like to submit a photo? (A photo is required)
Upload now By Mail (or upload later)
Photo upload notes:
1. File type must be a .jpg or .jpeg file.
2. Filename can only contain letters, numbers, dashes, and underscores. (No spaces!)
3. Filename must be shorter than 31 characters.
Photo:
Caption (optional): 

Submitter Information   Note: This information for clarification purposes only.
Name:
Address:
City:
State:
ZIP:
E-Mail:
Phone Number:
(With area code, no dashes, dots, or slashes)
Please verify the information above then check this box. (You must do this before "Submit" button will appear.)
The Hawk Eye
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Burlington, Iowa 52601
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