JACK DILLER EDUCATION AWARD Scholarship Application Form ...

JACK DILLER EDUCATION AWARD
Scholarship Application Form
PERSONAL INFORMATION
(Please type or print clearly)
Name: ________________________________________________________________________
Last First Middle
Name of high school you are currently attending: ______________________________________
Name and location of college/university you plan to attend: _____________________________
______________________________________________________________________________
Major and minor (if applicable): ___________________________________________________
For the academic year beginning ___________________ and ending _____________________
How did you hear about the Jack Diller Education Award? ______________________________
______________________________________________________________________________
Briefly explain any financial circumstances you would like us to consider: __________________
______________________________________________________________________________
Please list your other sources of financial assistance including scholarship awards: ___________
______________________________________________________________________________
Social Security Number:
Date of Birth:
__________-______ -__________
____________________________
Address: _____________________________________________________________________
______________________________________________________________________________
Home Phone: (_____)__________________Email: ___________________________________
Cell Phone: (_____)__________________ Best time to reach you: _______________________

Student’s Acknowledgement of Eligibility Requirements & Promotional Efforts
I certify that the information I have provided the Jack Diller Education Award committee for
consideration of a scholarship is true and correct to the best of my ability. I understand that any
false statements or misrepresentation of materials used and submitted to determine my eligibility
will automatically disqualify me from consideration. I understand that in the event I am awarded
a scholarship, I grant the Nashville Predators permission to use my name or photo and likeness
for the purpose of promoting this community outreach program and its results. I understand
publicity efforts will require my active participation and may include use of any media outlet,
including but not limited to radio, television and print. I understand the Nashville Predators
maintain all promotional rights. If I am awarded the scholarship, I understand that I must enroll
and attend college by the fall semester of the year following receipt of my award letter. After
this period, I recognize that I forfeit my right to the scholarship.
Date: __________________ ______________________________________________________
Student’s signature
Date: __________________ ______________________________________________________
Parent/Guardian’s signature
RETURN COMPLETED APPLICATION POSTMARKED OR HAND DELIVERED BY
FRIDAY, FEBRUARY 20, 2009.
Late or incomplete applications will not be accepted.

JACK DILLER EDUCATION AWARD
CHECK LIST
□ Completed application form (1 page)
□ Signed Eligibility Requirements & Promotional
Efforts form (1 page)
□ Essay (2-3 pages)
□ Two (2) letters of recommendation (at least one
from the teacher or coach who nominated you)
□ Official transcript
Please do not include this page in your submission.