Philip & Christabel Johnson Award

#BeloitProud Community Award

The information provided on this form will be used by the Miss Beloit Award/Scholarship Committee to select the recipient of this award. It is important that you give complete details. This will be a $500 award. Due March 15, 2025
BASIC INFORMATION
Full / Legal Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Birth Date

MonthDayYear
Academics
Academic GPA*
School Attending or Planning to Attend
School *
Major(s) You Are Considering

In order of preference, list the major(s) you are considering or have declared.
Major 1*
Major 2
PERSONAL DATA:
Elementary School(s) Attended*
Middle/Intermediate School(s) Attended*
High School Attending/Attended*
REFERENCES:

Please list one educator and at least one community person who would recommend you for an award.
Reference 1 Name (Position,Phone Number. email)*
Reference 2 Name (Position,Phone Number, email)*
SCHOOL / COMMUNITY ACTIVITIES / WORK / EXPERIENCE/SPORTS/AWARDS/ETC:

List name of club, etc. and years of participation. If you volunteered, list the name of organization and the number of hours, weeks and years that you volunteered. If you worked, list the company, hours per week and length of time. Attach an additional sheet or resume if necessary.
School Activities (not sports)
School Activities (not sports)
School Activities (not sports)
Community Service / Volunteer Activity *
Community Service / Volunteer Activity
Community Service / Volunteer Activity
Sports Participation 1
Sports Participation 2
Will you be participating in a sport(s) this year?

YesNo
Travel Experience or Unusual Experiences (study abroad, etc.)
School / Community Awards and Honors 1 (no matter how small) CSF, GSE, National Honor Society, Girl/Boy Scouts, 4-H, Governor’s Scholar, etc.
School / Community Awards and Honors 2
School / Community Awards and Honors 3
Parent/Guardian Name*
Parent/Guardian Name
Use this space to answer the following question: What makes you #BeloitProud? Make sure that you give vivid details (that can be personal) so that the committee fully understands why you are #BeloitProud. *
Submission Time

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

#BeloitProud Community Award

BASIC INFORMATION

Academics

School Attending or Planning to Attend

Major(s) You Are Considering

PERSONAL DATA:

REFERENCES:

SCHOOL / COMMUNITY ACTIVITIES / WORK / EXPERIENCE/SPORTS/AWARDS/ETC: