T.J. Samson Bowl
King Representative Application
Student Representative’s Name ______
Student Address: ______
Student Phone Number: ______
Student’s Parents/Guardians: Please list your name as you wish it to be announced at the TJ Samson Bowl on August 21, 2010.
______
______
Career Interest (field)
______
Please include a one to two, double-spaced document on the topic of your chosen health-related career.
2. Please list on an attached sheet various clubs and activities you have been involved in during your high school career. Also, please include various honors and awards you have received.
* CNS: Please see attached rating form for school activities/honors and awards. Provide to selection committee.
3. To be completed by the school guidance counselor:
Grade Point Average:
Rate Here:
ACT or SAT Score:
Rate Here:
*CNS: Please see attached rating form for GPA and test scores:
Guidance Counselor’s Signature Date
______
Student: Please return all materials to your guidance counselor no later than July 15, 2010.
King Rating Form
(to be completed by selection committee)
Student Representative’s Name : ______
Student’s Address: ______
Student’s Phone Number :______
Student’s Parents/Guardians: Please list your name as you wish it to be announced at the TJ Samson Bowl on August 21, 2010.
1. Career Interest (field) ______
Rate here : ______(up to 10 points)
*Committee: See the attached recommendation for rating this portion of the application.
2. School activities, honors, and awards.
Rate Here: ______(up to 20 points)
*Committee: See the attached rating form for activities, honors, and awards.
3. Rating below was provided by the counselors based on GSP rating guide:
Grade Point Average:
Rate Here: ______(up to 10 points)
ACT or SAT Score:
Rate Here: ______(up to 10 points)
*Counselors: see the attached rating form for GPA and test scores.
Guidance Counselor’s Signature Date
______
Total Points (up to 50) ______
Committee Member’s Initials ______
Please mail rating forms to Attn: Debbie Long, TJ Samson Community Hospital; 1301 North Race Street, Glasgow, KY 42141-3483. For questions call Debbie at 270.651.4711. Please mail forms no later than August 1, 2010. Thanks you!