Honoree NominationPlease enable JavaScript in your browser to complete this form. - Step 1 of 3Year the nominee is being nominated to be presented *2022-20232023-20242024-2025The nominee should be entering her junior year of College in the year that she is presented. Honoree InformationIMPORTANT: This nomination ballot is to be completed by the recommending person only. Under no circumstances should the proposed HONOREE know she is being considered! Please complete as much of the form as possible but NOT ALL FIELDS ARE REQUIRED. The inclusion of a photograph of the proposed HONOREE is necessary. Name *FirstMiddleLastPlease enter their full legal name, including middle names. Any nick names should be entered below.Nick NameNon-School EmailPlease enter a permanent email address. No school email addresses. Cell Phone *Home Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePlease enter a permanent mailing address. No school addresses or PO Boxes.High School *University *MajorHobbiesActive Organizations *Picture Upload * Click or drag a file to this area to upload. Please upload a candid photo of the honoree – Maximum Size 20 MBSocial Media ProfilePlease provide a link to a social media profile – ie. Facebook, LinkedIn, InstagramNextParents of Honoree InformationMother's Name *FirstLastBacchus Affiliation? *NonePast HonoreeOtherPlease indicate if the parent has an affiliation to the organization.Affiliation DescriptionIf "Other" above, please explain the affiliation to the organization.Deceased? *NoYesPlease indicate if the parent is deceased.Guardian NameFirstLastIf parent is deceased, please provide the name of the nominee's guardian.Mother's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIf deceased, please enter guardians address.Mother's EmailIf deceased, please enter guardians email address.Mother's Home PhoneIf deceased, please enter guardians home phone.Mother's Cell Phone *If deceased, please enter guardians cell phone.Father's Name *FirstLastBacchus Affiliation? *NonePast PresidentPast OfficerBaronOtherPlease indicate if the parent has an affiliation to the organization.Affiliation DescriptionIf "Other" above, please explain the affiliation to the organization.Deceased?NoYesPlease indicate if the parent is deceasedGuardian NameFirstLastIf parent is deceased, please provide the name of the nominee's guardian.Father's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIf deceased, please enter guardians address.Father's EmailIf deceased, please enter guardians email address.Father's Home PhoneIf deceased, please enter guardians home phone.Father's Cell Phone *If deceased, please enter guardians cell phone.Preferred ContactPlease indicate which parent you prefer us to reach out to regarding the nomination.Preferred Contact *MotherFatherGuardianPlease indicate which parent you prefer us to reach out to regarding the nomination.Preferred Contact Method *Home PhoneCell PhoneEmailTextPlease indicate the method by which the selected parent prefers to be contacted.Best Time(s) to Contact ParentPlease indicate the best day(s) of the week, and time(s) to contact the parent regarding the nomination.NextNomination Made ByName *FirstLastEmail *Phone *Bacchus Affiliation? *NonePast HonoreePast PresidentPast OfficerBaronPlease indicate if you have an affiliation to the organization.Affiliation DescriptionIf "Other" above, please explain the affiliation to the organization.Other Bacchus Members Endorsing Nomination EmailSubmit