NOMINATION FORM

Nominee's Name School

Home Address School Address
Home Phone ( ) School Phone ( )
Parent's Names Class in School Senior
Sport Coach's Name
Date Submitted Athletic Dir.'s Name
Athletic Achievement: (To be completed by Athletic Director or Coach)
Most Current Achievement (Please be specific - Date, Score, Accomplishment)
Other Sports Accomplishments
Examples of Leadership (Captaincies, Honors, Positions of leadership)
Statement from Coach Regarding Scholar-Athlete
Academic Achievement: (To be completed by Principal or Guidance Counselor)
Grade Pt. Avg._________ SAT Scores: R_______W_______M_______ Class Rank_______ # in Class_______
School & Non-School Activities (Extra-curricular organizations, Positions held, Clubs & Personal involvement in aiding others)
Comments (Please use reverse side if additional space is required)
Signature (Principal or Guidance Counselor)
APPLICATION DEADLINE: FEBRUARY 27, 2015
Application must be COMPLETELY filled out or will be disqualified. ALL information must be neatly printed or typed.
NEWS 12 NEW JERSEY & NJEA
SCHOLAR-ATHLETE
ACHIEVEMENT RECOGNITION
PROGRAM
Please submit nomination form with supporting documents using the following methods.
Mail : Cablevision, Attn: Deshanna Meyers-Scholar Athlete Program, 275 Centennial Avenue, Piscataway, NJ 08854;
Fax: 732-317-7295 or email: scholarathlete@news12.com. An application can also be found on www.njea.org or news12.com. Selections
for televised recognition will be made by the News 12 New Jersey Sports Staff. Nominations with new achievements may be submitted on a
weekly basis. Deadline to return applications is February 27, 2015.