Jr Cit Nomination Form
Name of Nominee
Date of birth (mm/dd/yyyy) (Cannot be older than 18 as of May 31, 2019)
Address (Mailing Address)
Nominee's Parent or Guardian
Parent or Guardian's Phone Number
Name of Nominator
Relationship with Nominee
Name of Nominee's School
Nominator's Local Newspaper
State your reasons for nominating this person.
Please describe the extraordinary circumstances (physical, emotional or environmental) that make this nominee's accomplishments significant.
Describe how this nominee has influenced others and why the efforts succeeded.
Describe how this nominee supports and helps at home.
Describe how this nominee's attitude toward life supports the nomination.
Add further comments or additional supporting materials you feel are important.