NOMINATION FORM 10 ON YOUR SIDE YOUNG ACHIEVERS “HAMPTON ROADS YOUNG ACHIEVERS” IS DESIGNED TO ENCOURAGE AND APPLAUD YOUNG PEOPLE WHO EXHIBIT EXCELLENT CHARACTER, COMMUNITY INVOLVEMENT, WISE USE OF LEISURE TIME AND A COMMITMENT TO ACHIEVING THEIR PERSONAL BEST. DATE: __________ CIRCLE GRADE: 8 9 10 11 12 NOMINEE’S NAME: _________________________ ADDRESS: _________________________ CITY, STATE & ZIP: _________________________________________________________________ PARENT OR GUARDIAN: _______________________ ADDRESS: _________________________ CITY, STATE & ZIP: ____________________________ PHONE: ___________________________ SCHOOL NAME AND ADDRESS: _____________________________________________________ ______________________________________________ PHONE: ___________________________ IN ORDER FOR THE JUDGES OF HAMPTON ROADS YOUNG ACHIEVERS TO MAKE AN EQUAL ASSESSMENT OF NOMINEES, PLEASE DESCRIBE THE FOLLOWING: LIST COMMUNITY INVOLVEMENT: 1. _________________________ DATES INVOLVED: _________________________ 2. _________________________ DATES INVOLVED: _________________________ 3. _________________________ DATES INVOLVED: _________________________ 4. _________________________ DATES INVOLVED: _________________________ 5. _________________________ DATES INVOLVED: _________________________ 6. _________________________ DATES INVOLVED: _________________________ 7. _________________________ DATES INVOLVED: _________________________ 8. _________________________ DATES INVOLVED: _________________________ LIST EXTRACURRICULAR ACTIVITIES (SCHOOL RELATED): 1. _________________________ DATES INVOLVED: _________________________ 2. _________________________ DATES INVOLVED: _________________________ 3. _________________________ DATES INVOLVED: _________________________ 4. _________________________ DATES INVOLVED: _________________________ 5. _________________________ DATES INVOLVED: _________________________ 6. _________________________ DATES INVOLVED: _________________________ 7. _________________________ DATES INVOLVED: _________________________ 8. _________________________ DATES INVOLVED: _________________________ WAVY TV 10, 300 WAVY STREET, PORTSMOUTH, VA 23704 757-393-1010 FAX 757-399-7628

PLEASE MAIL NOMINATION TO: CHARACTER AND PERSONAL BEST (to be filled out by nominator): Explain how the student’s activities build character, create a positive attitude, provide discipline or enhance self-determination. STUDENT STATEMENT: Nominees need to describe in their own words how their activities help them to become responsible citizens and how they have a positive effect on their school and community. PLEASE LIMIT ADDITIONAL MATERIAL TO ONE PAGE. REFERENCES: Please supply information on two other persons that can speak to the qualifications of this nominee: NAME _________________________ OCCUPATION _________________________ ADDRESS ______________________ PHONE _______________________________ PERSON MAKING NOMINATION _________________________ PHONE _________________________ ADDRESS ____________________________________________________________________________ PLEASE MAIL NOMINATION TO: HAMPTON ROADS YOUNG ACHIEVERS c/o WAVY TV 10 300 WAVY STREET PORTSMOUTH, VA 23704 Nominations accepted August 22, 2011 through mid April 2012 COPIES MAY BE REPRODUCED