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NOMINATION FORM DEADLINE: OCTOBER 21, 2016 Date: Additional forms may be copied or downloaded online at www.modestogov.com. An accurate address and phone number for the nominee is critical so that we may contact him/her if selected. NOMINEE: Name: T-Shirt Size: Home Address: Mailing Address: _ City: State: _ Zip Code: _ Home Phone Number: ( ) Email: Current Grade: 11 ( ) 12 ( ) Graduation Year: Date of Birth: Name of Nominee’s School: School’s Phone Number: ( ) Home Schooled? (this does not affect the score): NOMINATOR: Name: Relationship to Nominee (may not be the nominee’s parent): Mailing Address: City: State: _ Zip Code: _ Daytime Phone Number: ( ) _ Evening Phone Number: ( ) S UBMIT YOUR APPLICATION BY: U.S. Mail: Email to: Fax: City of Modesto [EMAIL REDACTED] (209) 571-5128 Mayor’s Top Teens P. O. Box 642 Modesto, CA 95353 PLEASE CONTINUE ON OTHER SIDE. “Neighborhood Engagement and Education Partnerships” 2016-2017 Mayor’s Top Teens Print Form Submit by Email ---PAGE BREAK--- Provide a detailed response for each category below. If needed, one additional page may be attached. It is important to be as specific and detailed as possible. Each category will receive points based on the content of your responses. All candidates will be ranked by the combined point total of these categories. Overcame an obstacle: Lived a life of service: _ Attained a significant accomplishment: Well-rounded (type of activities – sports, the arts, work, academic honors): Any other important information about the nominee: I believe the teen I am nominating does not normally receive recognition and would benefit from this honor. I believe the enclosed information to be true and accurate to the best of my knowledge. Signature of Nominator Date P.O. Box 642 Modesto, CA 95353 www.modestogov.com