NOMINATION FORM 
TEENAGER OF THE MONTH 
SPONSORED BY 
THE BENEVOLENT AND PROTECTIVE ORDER OF ELKS
Nominees will be judged on the basis of character, leadership, service, citizenship, and scholarship.  Answer in as much detail as possible.  When necessary please attach a separate sheet.

Nominee’s Full Name			   	_____________     	___________					   Last         			First 			Middle
Parent’s Name ____________________________________________________
Address    ____________________ City, State, &Zip ______________________
Home Phone ____________            Birth Date	____________________
EDUCATION
Attends      Upper Scioto Valley High School                     High School Grade __
Below state your future plans after graduating from High School.
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WORK EXPERIENCES
List and briefly explain any work experiences of the nominee, including full time employment, part-time work, summer jobs, etc., whether paid or unpaid.  Give the years these positions were held.
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COMMUNITY SERVICE
List and briefly explain volunteer work provided by the nominee for the good of the community as a whole or for individuals within the community.   Give the years you performed these works.
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SCHOOL INVOLVEMENT 
List all school activities (academic, athletic, service, or social) in which the nominee has participated.  Please indicate the year(s) of participation with the (9, 10, 11, 12) designation, and note any awards or recognition.
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NON-SCHOOL INVOLVEMENT.
List all non-school activities (club, church, service, or social) in which the nominee has participated.  Please indicate the number of years of participation with the (2 yrs., 3yrs., etc.) designation, and note any awards or recognition received. 
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LEADERSHIP ROLES
List any offices held in any school or non-school activities in which the nominees has participated.  Please indicate the years in which the office was held.
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NOTE:  If more space is needed, please attach a separate sheet.