State:

Building a Brighter Future:

Summit Utilities' Commitment to Community and Education through STEAM

Summit Utilities STEAM Student of the Month Application Form

Thank you for your interest in Summit’s STEAM Student of the Month initiative with THV11. Please fill out the following information to submit an outstanding student for consideration.

Student Information

Student's Name

School Attending:

Current Grade:

List accomplishments achieved in STEAM by the student:

Which element(s) of STEAM does the student excel in? Please explain:

Please list any extracurricular activities at school the student participates in:

Does the student participate in any volunteer work? If yes, please describe:

Any final remarks on why you are recommending this student?

Submitter's Name (Parent/Guardian):

Relationship to Child:

Submitter's Phone Number:

Submitter's Email Address:

Media Release Consent:

I, hereby authorize THV11 and Summit Utilities to use my photo, video, and likeness for the purpose of promotion in news releases, photographs, video, audio, website, marketing and advertising for an indefinite period of time.

If I am under the age of 18, my undersigned parent or legal guardian is executing this release on my behalf and agrees to be bound by its terms.

Parent/Guardian First Name:

Parent/Guardian Last Name:

Parent/Guardian Signature:

Date:

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