Kiwanis Club of Richmond, Kentucky
George Brown Kiwanis Scholarship

Model High School Key Club Nomination Form

Typed forms are preferred but handwritten ones are acceptable. On separate sheets, please include:
(1) a reference letter from a school representative, (2) a reference letter from a community
representative, and (3) an essay entitled Why I Would Like to Receive the Kiwanis Scholarship that
is no longer than one page. Please turn in completed application to Beth Thompson, Kiwanis Club Scholarship Chairperson, no later than May 1st.

Students Name _______________________________ Students Signature__________________________
Sex____Date of Birth__________Phone Number:______________Alternate Phone Number:____________
Address ________________________________________________________________________________
Street City State Zip
School __________________________________________ Date of Graduation _______________________
Parents/Guardians ___________________________________
Fathers/Guardians Full Name
Mothers/Guardians Full Name
E-mail Address __________________________
Course of Study in High School ______ Advanced _____ General _____ Other __________________
Cumulative Grade Point (Based on 4.0) ___________
ACT Composite ______or SAT Scaled Scores_________________________________________
Number in Graduating Class ____________ Your Rank ____________
Scholarships received:

College plans (school, major):

High school activities/honors:

Leadership and contributions to the Key Club:

Leadership and community service:

Prior employment (full-time or part_time):


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