Blue KC Sporting Samaritan Nomination Form

Blue KC Sporting Samaritan Nomination

Please complete the information below to nominate someone as next month's Blue KC Sporting Samaritan!

Nominator Information

Nominator Name*

First Name

Last Name

Nominator Email*

Nominator Phone Number*

Nominator Zip Code*

Nominee Information

Nominee Name*

First Name

Last Name

Nominee Email*

Is your nominee a student, teacher or teacher/coach?*

Student Teacher Teacher/Coach

Other:

What school do they attend and what grade are they?*

What school do they teach at?*

What school do they teach/coach at?*

Explain why your nominee should be selected as a Blue KC Sporting Samaritan.*

Please limit to 250 words or less.

To the best of your knowledge, is this person recognized as an outstanding student and person of good character by other students? *

Yes No

To the best of your knowledge, is this person recognized as an outstanding educator and person of good character by other colleagues?*

Yes No

To the best of your knowledge, is this person recognized as an outstanding role model and person of good character by their peers?*

Yes No

Is the nominee willing to be included in a press release if selected?*

Yes No

Does the nominee live within a 75 mile radius of Children's Mercy Park?*

Yes No

How did you hear about Blue KC Sporting Samaritan?*

Sporting KC match Radio Sporting KC website Social media Word of mouth School district

Other:

Check all that apply.