Community Champions Award

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Student Information

Student First Name

Student Last Name

Student Phone

Birth Date

Student Mailing Address

Student City

Student State (Two Letter Abbreviation)

Student Zip Code

Student Email

Name of High School

Official School Transcript or Enrollment Letter

High resolution photo of student (by uploading this you acknowledge consent for PPEC to publish this image)

Record Type ID

Community Impact

Why is giving back important to you? How do you plan to continue making a difference in the future?

Briefly tell us how how you are making an impact locally and giving back to the community (No more than 500 words) *This can be written by someone other than the student themself.

Parent/Guardian Information (If High School Student or Minor)

First Name of Parent or Guardian

Last Name of Parent or Guardian

Additional Name of Parent or Guardian

Parent Phone

Parent Mailing Address

Parent City

Parent State (Two Letter Abbreviation)

Parent Zip Code

Parent Email

Education Information

What college(s) or accredited technical school(s) have you been accepted?

Did you declare a major, and if so, what?

Will you start this education/schooling within 12 months?

YesNo

What month and year do your courses start?

STUDENT ACKNOWLEDGEMENT

I (student) have examined this application, and the records are true, complete, and accurate. In addition, I acknowledge and agree that the Cooperative, Ohio’s Electric Cooperatives, Inc., and Indiana Electric Cooperatives may disclose any or all of the information contained in this application and the supporting documents to the judges of the competition and to any employees of the Cooperative or of Ohio’s Electric Cooperatives, Inc. and Indiana Electric Cooperative.

I also consent and agree that Paulding Putnam Electric Inc. (PPEC), its employees, and agents have the right to take photographs, videotape, or digital recordings of me to use in any and all media. I agree that PPEC may use such photographs and media of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, web content, and the cooperative's magazines.

By typing your name below, you are providing an electronic signature.

First Name

Last Name

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Contact Information