|
Date_______________ State (where
nominee resides)___________________________
Student Information
Name________________________________________________________________________
Address_____________________________________________________________________
City/State/Zip______________________________________________________________
Phone
number(day)___________________________________________________________
Birth date__________________ Grade (at time of
application)________________
Social Security No. (necessary for Bond if
awarded)_________________________
Name of
parent/guardian_____________________________________________________
(Address if different from
above)___________________________________________
____________________________________________________________________________
(Phone number if different from
above)______________________________________
School
name_________________________________________________________________
School
address______________________________________________________________
____________________________________________________________________________
Teacher's
Name______________________________________________________________
Name of person nominating
student___________________________________________
Address_____________________________________________________________________
City/State/Zip______________________________________________________________
Phone(day) and
e-mail_______________________________________________________
Relationship to
nominee_____________________________________________________
ENCLOSURES
Student Composition
Letter of Recommendation (from someone other than family member)
Signed Release Form
Photo (in a sealed envelope)
Self-addressed, stamped postcard
Submit form and enclosures, postmarked no later than April 30 to:
MAGE Awards Committee
c/o Laurence Osborne
88 North Street
Middleboro, MA 02346
Awards Page
M.A.G.E.
Home Release Form
|