Kevin Lewis President's Scholarship Application
All Fields Required
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Applicant
First Name
Middle Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Name of Parent/Grandparent/Guardian
First Name
Middle Name
Last Name
How many years has Parent/Grandparent/Guardian been a member of the IOA:
Parent/Grandparent/Guardian Phone Number
Please enter a valid phone number.
Parent/Grandparent/Guardian Email Address
example@example.com
High School Attendance Record
Post-secondary college, university, trade school, vocational program, etc., for which you are requesting aid and the subject area or vocational area you plan to pursue.
Tell about the school or community activity in which you have been most involved during your school years. Tell how long you have been involved, how much time (per week, per year, etc.) that you have participated and why you have decided to devote your time to this activity.
Make a statement of your future aspirations.
State how your parent's/grandparent's/guardian's involvement in officiating high school athletics has influenced you.
With the completed application, please confirm that you have emailed the following to jdizney@speedwayschools.net:
READ THE FOLLOWING BEFORE SIGNING THE FORM: We declare the information on this form to the best of our knowledge is true, correct, and complete. We understand the Selection Committee may request additional information by means of a personal interview with the applicant. We understand that incomplete or false information could result in disqualification.
Parent, Grandparent, or Guardian Signature
Parent/Grandparent/Guardian Phone Number
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
I hereby give my permission to the respective high school that I attend to release to the Indiana Officials Association Selection Committee, a copy of my transcript of grades with the application.
Applicant's signature:
Parent/Grandparent/Guardian's Signature:
Continue
Continue
Should be Empty: