Youth Bureau

Student of the Week Nomination Form

This form is for the nomination of a student of Cattaraugus County for the Cattaraugus County Youth Citizenship Award.

2008-2009 School Year

If you would like to mail us your nomination then please download the Nomination Form in PDF. Print the form and fill it out.

Nominee Information

Name of Student

Name of School

Grade

Year of Graduation

Student's Address

Student's Phone

Date of Birth

Parent or Guardian 1

Parent or Guardian 2

Nominator (you)

Nominator Name

Relation

Email Address

Phone Number

Community Service and Citizenship

Organizations (i.e. youth groups, religious groups, Scouts, 4H, etc.) Years of Service / Leadership Role

(For religious groups, please state name of church)

Community Service Involvement Years of Service / Leadership Role

Extracurricular Activities

(Please list all school-based extracurricular activities in which the student currently is participating in, i.e. Honor Society, math clubs, key club, band, chorus, SADD, Youth Court, peer leadership groups, etc.)

Non Sporting Year(s) Participating/ Leadership Role

(For band, please state instrument that you play)

Sports Teams Year(s) Participating / Leadership Role

Educational Record

Grade Point Average (GPA)

Class Rank (if applicable)

Number of People in your Graduating Class

Scholarships or Academic Awards

Personal Information

1. Interests / Hobbies

2. Activities Related to Helping or Serving Fellow Youth

3. Future Goals/Aspirations

Rationale

Why are you nominating this particular student?

CattCo.org: Cattaraugus County Web Site

Student of the Week Nomination Form

2008-2009 School Year