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BlueShield Scholars Nomination Form

To nominate a student from your school, please complete and submit this form electronically by April 20th.

 

The nominee must be someone who is planning to pursue higher education in the fields of health or human sciences and demonstrates teamwork, integrity, personal responsibility, passion, excellence, and respect - our core values.

 

We will notify you by April 20th if your student has been selected as a 2018 BlueShield Scholar.

 

If you have a concern about the deadline or have any other questions, please contact Nicky Chlopecki by email, chlopecki.nicole@bsneny.com, or phone, 518-220-4863.

 

*Your nomination is not complete until we receive the student photo and photo release form.

 

*Please e-mail your signed photo release form to communityrelations@bsneny.com

 

Contact Information

Nicky Chlopecki
518-220-4863
chlopecki.nicole@bsneny.com


Student Photo

PHOTO GUIDELINES: Please submit a color photo in a jpeg format. Senior portraits are ideal. Photos need to be high resolution as they will appear in a special insert in the Albany Business Review and in a featured article on our website.

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Nominating Principal/Guidance Counselor

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School Information

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5-digit zip code

Student Information

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5-digit zip code
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Statements submitted below will be used in a special feature article on our websites that profiles all BlueShield Scholars. We know that many students are inspired to enter the field of health and human sciences because of a medical issue in their life or that of a family member. Please tell us your story, but note that mentions of protected health information cannot be published. Protected health information (PHI) is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual.

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If yes, please provide information about the assembly:

 
 
 

Please provide information about the assembly coordinator if it is different from yours:

 
 
 

Authorization

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 I verify that all information is correct. Ultimate determination of whether, and in what context, to use my nomination form, name and title is solely within BlueShield’s discretion and I release them from any liability arising out of such use.