Annual Outstanding Youth Award Nomination Form

Name of Nominee:     Age/Birthday:
Nominee's Address:
Name of Parent/Guardian:
Parent/Guardian Telephone #:
School:                Grade: K 1 2 3 4 5 6 7 8 9 10 11 12 Other

Name of Nominator:   Relationship:
Nominator's Address:
Nominator's Telephone #:

Name of One Reference:
Reference Address:
Reference Telephone #:

Give examples of ways this individual has helped others:

Any volunteer, work, or community service performed?  Please describe:

List any extra curricular activities, clubs, or organizations nominee belongs to:

Has the nominee received any other awards or distinctions?  Please list:

Please list any other information you feel is important for the selection committee to know about your nominee:

Nominee's Future Plans:

Due Date: March 20