NOMINATION FORM

I received this application from...

a “Champion”

Name: ______________________________________________

an “Ambassador”

Name: ______________________________________________

a teacher

Name: ______________________________________________

Other (please identify):

____________________________________________________

I am applying for the first time.

I have been a Champion” for ■■ years.

I have been an Ambassador” for ■■ years.

Name: ____________________________________________________ Date of Birth: ____________________________

Address: ____________________________________________________________________________________________

City: ____________________________

State: ____________

ZIP: ____________

County: ________________

Home Telephone: ____________________

Cell Phone: ______________ E-Mail: ________________________________

Grade: __________ School: ______________________________________

School Phone: ________________________

School Address:________________________________________________________________________________________

City: __________________________________________

State: ____________________

ZIP: ________________

Principal: ______________________________________

 

 

 

 

School Service Coordinator/Guidance Counselor: ____________________________________

Superintendent: ______________________________________________________________

Name of your neighborhood newspaper(s): __________________________________________________________________

Name of local cable company or station: ____________________________________________________________________

Have you been a student in the Journey of a Champion curriculum?

Yes No

 

If yes, please provide the following information:

 

 

 

 

School: ____________________________________

 

 

 

 

Teacher: ____________________________________

Grade:

__________________

Year: ________________

Subject: English Social Studies Other: ________________________________

 

Was special training provided before any of your service projects?

Yes

No

 

If yes, which project(s)? ____________________________

How many hours? __________

 

Describe the training: __________________________________________________________________________________

Optional: For research and funding purposes, please check the appropriate boxes below.

Race/Ethnicity:

 

 

African American/Black

Asian American

Multi-racial

Latino/Latina

White/European American

 

These do not apply to me. I identify myself racially/ethnically as __________________________

Gender: Male Female

Religion/Faith Community:

If you identify with a particular faith/tradition, please indicate: ______________________________________________

COMMITMENT FORM

If chosen to be a “Champion/Ambassador of Caring,” I will continue to be involved in service projects in my community.

____________________________________________________________________________________________________

Print Name Signature Date

If I/my child is chosen as a “Champion/Ambassador of Caring,” I hereby give the Champions of Caring organization permission to use my/my child’s photographs, videos, essays, or project descriptions in promotional materials.

____________________________________________________________________________________________________

Signature of Parent/Guardian or Student if 18 years or older Date