Please complete all sections of this form.
Student's Full Name*
Parent/Guardian Name(s)*
Complete Home Address*
Student's Phone Number*
Parent/Guardian Phone Number*
Name of School*
Current Grades or GPA*
Extracurricular Activities and Hobbies*
Community Service and Volunteer Activities*
Total Community Volunteer Hours*
Employment Information (enter N/A if not employed)*
Future Plans: College, Training or Employment (1 or 2 sentences)*
Permission to Publish and Post
By checking this box and submitting this form, you give Newark Elks Lodge #391 permission to use your name and photograph to recognize you as a Newark Elks Senior Shoutout on social media and in community newspapers, Ohio Elks News and The Elks Magazine.
