Student Scholarship Nomination Form

Nomination Form for High School Blood Drive Scholarship

Provide all information requested below and submit by June 23rd, 2026. Late applications will not be accepted. If you are splitting the scholarship, we need separate forms for each student with a note.

Name

This field is for validation purposes and should be left unchanged.

Name of High School(Required)

School Designee submitting the Nomination(Required)

First Last

School Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Name of Principal(Required)

First Last

Blood Drive Faculty Advisor(Required)

First Last

Number of Students in Senior Class(Required)

Number of Students in Junior Class(Required)

Student Nominee Information

Scholarship Nominee(Required)

First Last

Student's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Student's Phone

Student's Email

Name of College Student is Attending(Required)

Senior Award Event Information

Date of Senior Award Program(Required)

Time(Required)

We will attempt to have the check/certificate to you in time for your award ceremony for applications submitted by the deadline (those not prepared in time will receive a promise note in the meantime. Check processing takes 60 days (about 2 months) from submission.

Will you permit the NYBC representative to present the scholarship award and make a few brief remarks?(Required)

Yes

If yes, please provide the following:

Arrival Time

Event Start Time

Anticipated Duration

Location