Harry Jerome Scholarship Award 
Athletics (Track & Field, Road & Cross Country Running) Achievements

School / Club Coach:_______________________________________________________

Club:____________________________________________________________________

B.C. High School Championship participation (T&F-Track & Field, CC-Cross Country):

Championship Year Event Performance Placing
         
         
         
         
         

Best performances of the last 3 years:

Event Year Meet/Race Performance Placing
         
         
         
         
         

BC Athletics Provincial Teams or Athletics Canada Teams you competed for 
in the last 3 years:

Year Teams
   
   
   

Projected performance(s) for current year:

Event & Performance Event & Performance Event & Performance
     
     
     

Overall goal in Athletics (track & field/cross country/road running):____________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Signatures required:

          Applicant:_________________________________ Date:__________________

              Coach:_________________________________ Date:__________________

School Principal:_________________________________ Date:__________________