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Kindness Campaign Nomination Form

Information about the young person you have nominated for this award:

Information about his/her parent/guardian(s):

References: Please list 2 people who are familiar with the accomplishments of this nominee:

Please be specific as to why you think your nominee should receive this award. The more information you include, the easier it will be for the screening committee to recognize what makes this young person so deserving of this special award.

Name:*

Address:*

City:*

State:*

Zip:*

Age:*

Grade:*

School:*

Name:*

Address:*

City:*

State:*

Zip:*

Telephone:*

Email:*

Relationship to Nominee:*

Name:*

Address:*

City:*

State:*

Zip:*

Telephone:*

Email:*

Name:*

Relationship to Nominee:*

Telephone:*

Nomination:*

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