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STUDENT POLLWORKER PROGRAM NOMINATION FORM CITY OF MIDDLETON NAME: HOME ADDRESS: E-MAIL: T CITY: ZIP CODE: DATE OF BIRTH: N LANGUAGE: PHONE: E D x A HIGH SCHOOL STUDENT WITH A GPA OF AT LEAST 3.0 U x UNITED STATES CITIZEN AT THE TIME OF THE ELECTION T x AT LEAST 16 YEARS OF AGE AT THE TIME OF THE ELECTION S STUDENT SIGNATURE DATE T NAME: N EMERGENCY PHONE NUMBER ON ELECTION DAY: E THIS IS TO GIVE PERMISSION FOR MY DAUGHTER/SON, NAMED ABOVE TO SERVE AS A POLL WORKER. R A PARENT SIGNATURE DATE P TEACHER/ADMINISTRATOR: L HIGH SCHOOL: O CONTACT NUMBER: O AS A TECH/ADMINISTRATOR AT MIDDLETON HIGH SCHOOL, I VERIFY THAT THE ABOVE NAMED H STUDENT MEETS THE ELGIBILITY REQUIREMENTS AND WOULD BE AN OUTSTANDING STUDENT POLL C WORKER. S TEACHER/ADMINISTRATOR SIGNATURE DATE N CITY OF MIDDLETON R CITY CLERK'S OFFICE U 7426 HUBBARD AVENUE T MIDDLETON, WI 53562 E R BY E-MAIL: [EMAIL REDACTED] I UNDERSTAND THAT I MUST MEET THE FOLLOWING REQUIREMENTS TO BE ELIGIBLE FOR THIS PROGRAM: x A STUDENT IN GOOD STANDING