Super Scholars Student Bio Form

Congratulations on being selected as Super Scholar recipient. Please complete the entire form and click the submit button. Please note that this is not an RSVP to the event. The information will help us to create an introduction for you at our banquet.

* Required Field

Student Information

Student Name *

Preferred Pronouns *

High School *

Home Address *

City *

State *

Zip *

Email Address *

Phone *

Parent or Guardian 1

Name *

Phone *

Email Address *

Relationship to Student *

Parent or Guardian 1 Address Same as Student

Home Address *

City *

State *

Zip *

Parent or Guardian 2

Name *

Phone *

Email Address *

Relationship to Student *

Parent or Guardian 2 Address Same as Student

Home Address *

City *

State *

Zip *

Educator/Mentor

Please name the educator/mentor who has had a positive influence on your education. (They will be invited to attend the banquet as your guest.) *

Educator/Mentor Email Address *

School Where Educator/Mentor Taught You *

Educator/Mentor School Address (If Different Than Your Current School) *

City *

State *

Zip *

Other Student Info

List Your Top 3 Notable Achievements/Awards (250 Chars Max) *

What Are Your 3 Main Interests Outside of Academics? (i.e., extracurricular activities, hobbies, etc.) (250 Chars Max) *

What Career Plans Are You Have/Are Considering? (250 Chars Max) *

Which University/College(s) Are You Planning To Attend? If Undecided, List Top 3 Preferences. *

Dietary Restrictions

Are there any dietary restrictions of which we should be aware?

Student *

Yes (Please Describe Below)

Describe Dietary Restrictions

Guest 1 *

Yes (Please Describe Below)

Describe Dietary Restrictions

Guest 2 *

Yes (Please Describe Below)

Describe Dietary Restrictions

There was an error submitting the form

Choose a text color for the subhero caption below.

A Symbol of STRENGTH for More Than a Century