DISTINGUISHED STUDENT AWARD NOMINATION FORM 2014-2015
Nominated By: ______Date: ______
Nominator’s Position: Principal ( ) Counselor ( ) Teacher ( )
Nominator’s Email: ______
Nominator’s Work Phone: ______
Please attach student resume on separate sheet of paper and turn this form into your school principal or school counselor. Thank you for your participation. For additional nomination forms go to: www.DistinguishedStudentAward.com.
Please send your DSA nomination to the contact listed below for your market.
Treasure Valley:
Traci Liew • KTVB TV • PO Box 7 • Boise, ID 83707 • (p) 208-321-5717 • (f) 208-321-5642 •
Magic Valley:
Deanna Magaw • KTFT TV • 834 Falls Ave. • Twin Falls, ID 83301 • (p) 208-736-5081 • (f) 208-734-3981 •
Eastern Idaho:
Gina Berger • KIFI TV • 1915 N. Yellowstone Hwy • Idaho Falls, ID 83401 • (p) 208-525-8888 • (f) 208-522-1930.
North Idaho:
Kirsten Rosman-Russell • KREM TV • 4103 S Regal St. • Spokane, WA 99223 • (p) 509-838-7318 • (f) 509-448-2090
The DSA airs every Thursday in the 10PM (MST) newscast on KTVB-TV and KIFI-TV
The DSA airs every Thursday in the 6PM (PST) newscast on KREM-TV
The DSA airs every Thursday in the 6PM (MST) newscast on KTFT-TV.
All DSA stories are archived on KTVB.com/distinguished-student.
DISTINGUISHED STUDENT AWARD NOMINATION FORM 2014-2015 (cont.)
Student Name: ______Date: ______
Student Phone: ______Student Email: ______
Student Address: ______(Street, PO Box)
______(City, State)
Age: ______
GPA: ______
High School Name: ______
School Phone: ______
School Address: ______
Please list examples of exemplary academic achievement that demonstrate the reasons why this graduating senior is worthy of receiving the United Dairymen of Idaho’s Distinguished Student Award. (academic awards, elevated GPA, college preparatory classes, Honor Society member, and class schedule degree of difficulty, etc.)
______
Cite examples of community involvement activities in which this student has participated. (Volunteerism, fundraising, mentoring, etc.)
______
DISTINGUISHED STUDENT AWARD NOMINATION FORM 2014-2015 (cont.)
Please list any extracurricular school activities in which this student has participated. (clubs, leadership programs, student body officer, leadership positions, band, choir, debate, athletic teams, etc.)
______
Please list any applicable distinguishing credentials. (honors, awards, talents, hobbies, bilingual, foreign exchange programs, etc.)
______
What are the student’s future plans? If the student plans to attend college, where? What is his/ her expected area of study? Where does he/she plan to attend college?
______
Please send your DSA nominations to:
Traci Liew
KTVB Community Service Director
KTVB-TV
5407 Fairview Avenue
Boise, Idaho 83707
Phone: 208-321-5717
Fax: 208-321-5642
Email: