MBA State Clinic Student Nomination List
Check with your students regarding their availability to participate on these dates BEFORE nominating them. December 10 IS AN ACT ADMINISTRATION DATE.

List your best musicians first. Due to instrumentation limitations, the first student listed will NOT be guaranteed.

Nominate only those students who perform well and who will represent you, your school and your community in a positive manner.

You MUST nominate 8 students. High schools with less than 8 names listed will only have ONE student selected.

Junior high/middle schools must also submit 8 names; one student will be selected.

High school directors are expected to communicate with Junior High Directors and have them fill out a nomination form if needed.

This form should be submitted BY SEPTEMBER 15.

Directors must have paid their $80 dues in order for their nominations to be accepted.

Please mail MBA dues to:
Len Killough,
1st Vice President, MBA
805 Dilworth Lane
Hernando, MS 38632


Director First Name
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Director Last Name
Your answer
School Name
Your answer
School Type
School Phone
Your answer
Cell Phone:
Your answer
Director Email Address:
Your answer
Student 1 Information
Student First Name 1
Your answer
Student Last Name 1
Your answer
Instrument 1
Student Gender 1
Student Age 1
Years In Band 1
Student 2 Information
Student First Name 2
Your answer
Student Last Name 2
Your answer
Instrument 2
Student Gender 2
Student Age 2
Years In Band 2
Student 3 Information
Student First Name 3
Your answer
Student Last Name 3
Your answer
Instrument 3
Student Gender 3
Student Age 3
Years In Band 3
Student 4 Information
Student First Name 4
Your answer
Student Last Name 4
Your answer
Instrument 4
Student Gender 4
Student Age 4
Years In Band 4
Student 5 Information
Student First Name 5
Your answer
Student Last Name 5
Your answer
Instrument 5
Student Gender 5
Student Age 5
Years In Band 5
Student 6 Information
Student First Name 6
Your answer
Student Last Name 6
Your answer
Instrument 6
Student Gender 6
Student Age 6
Years In Band 6
Student 7 Information
Student First Name 7
Your answer
Student Last Name 7
Your answer
Instrument 7
Student Gender 7
Student Age 7
Years In Band 7
Student 8 Information
Student First Name 8
Your answer
Student Last Name 8
Your answer
Instrument 8
Student Gender 8
Student Age 8
Years In Band 8
Other Comments:
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