The Rockford Register Star is seeking outstanding teenagers to become the Young
Americans of 2011. Please provide the following nominee information in a
legible manner. One form and one additional page (if necessary) per nominee.
You many nominate up to five (5) people. Nominee must be between the ages
of 13 and 19 as of March 1, 2011 and reside within the Rockford Register
Star’s circulation area. Deadline for submittal: 5:00 p.m. C.T. Friday,
March 18, 2011.
First Name:
Middle Name:
Last Name:
Age:
Date of Birth:
Parent's Names:
Address:
City:
State:
Zip:
School:
Grade:
G.P.A:
REASON FOR NOMINATION: (Act of bravery, exemplary character, community service, group leadership, etc.)
COMMUNITY SERVICE AND ACTIVITIES: (List in order of importance.)*
SCHOOL AND EXTRACURRICULAR ACTIVITIES: (List order of importance.)*
After school or summer jobs: (List jobs during high school only.)
Plans after high school; after college:
AWARDS AND RECOGNITIONS RECEIVED: ( List in order of importance.)*
OTHER: In your estimation, what sets this nominee apart from other nominees? (Please be specific.)*
Nominator's Name:
Address:
City:
State:
Zip:
Phone: (work) :
(phone):
Signature:
Title, Position:
Affiliation to Nominee:
