Republic Central Colleges

Angeles City

HIGH SCHOOL DEPARTMENT

RCC High School Leadership Award 2019-2020
NOMINATION FORM
The ____________________________________________________________________ is honored to nominate
(organization/ club)

____________________________ of ________________________ to the RCC HS Leadership Award 2020.

(nominee) (Grade & Section)

( ) Junior High Category ( ) Senior High Category

This nomination is a tribute to his/her track record of excellence in leadership and to his/her exemplary achievements
and accomplishments as a student.

Nominator (Mr./ Ms./ Mrs./ Dr.): _____________________________ Designation: _____________________

(please encircle appropriate title) Signature Over Printed Name

INSTRUCTIONS: Please use black ink and print legibly or use a typewriter. Submit this original copy with 1 colored photo of
the nominee with supporting documents duly signed in a clear book. Please follow carefully all the instructions in each item.

I. PERSONAL INFORMATION

Full Name ______________________________________________________________ Please attach recent colored

Surname Given Name Middle Name (2 x 2 photo)

Home Address __________________________________________________________

Residence No. Street District/Town/Barangay City/Province Zip Code

__________________________________________________________

Age: Birth Date: Place of Birth:

Religion: Mobile No.: E-Mail:

Guardian: Guardian’s Mobile Number:

I. SCHOOL INFORMATION

YEAR
NAME OF SCHOOL SCHOOL ADDRESS AWARDS (if any)
ATTENDED

PRE-ELEMENTARY

ELEMENTARY

JUNIOR HIGH
SCHOOL

SENIOR HIGH
SCHOOL

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 Republic Central Colleges
Angeles City

HIGH SCHOOL DEPARTMENT

II. POSITION/S HELD DURING JUNIOR HIGH SCHOOL IN RCC

ACADEMIC YEAR NAME OF CLUB/ORGANIZATION POSITIONS HELD Corresponding

Page

Note: Use additional sheets if necessary. Attach supporting documents duly signed in the exhibit. Label
properly.

III. ACHIEVEMENTS/AWARDS (Academic and Non-Academic)

ACADEMIC YEAR CONTEST/GAMES/EVENT PARTICIPATED AWARD/

Corresponding
CITATION/PLACE Page
RECEIVED

Note: Use additional sheets if necessary. Attach supporting documents duly signed in the exhibit. Label
properly.
IV. POSITION HELD

V. TRAININGS, SEMINARS, WORKSHOPS, CONVENTIONS, SYMPOSIA ATTENDED/PARTICIPATED TO

INCLUSIVE DATE SPONSORING ORGANIZATION VENUE Corresponding

Page

Note: Use additional sheets if necessary. Attach supporting documents duly signed in the exhibit. Label
properly.
V. POSITION HELD

VI. ACTIVITIES/ PROJECTS/PROGRAMS INITIATED/CO-INITIATED/PARTICIPATED TO AS PART OF THE

ORGANIZERS

NAME OF THE EVENT/PROJECT/PROGRAM

ROLE (Initiator/Co- Corresponding
INCLUSIVE DATE (Indicate whether in-school, division, or regional
Initiator/Others) Page
level, etc.)

Note: Use additional sheets if necessary. Attach supporting documents duly signed in the exhibit. Label
properly.

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 Republic Central Colleges
Angeles City

HIGH SCHOOL DEPARTMENT

VII. ACADEMIC STANDING/ PERFORMANCE AS OF THE

CURRENT ACADEMIC YEAR

ACADEMIC YEAR GENERAL WEIGHTED AVERAGE (GWA) REMARKS

rd
3 Grading (JHS)
2nd Sem, 1st Grading (SHS)
2018-2019

VIII. CERTIFICATION BY THE NOMINEE

TO THE SCREENING COMMITTEE:

I hereby certify to the best of my knowledge that all the information contained in this form is true and correct.
I am aware that any willful misrepresentation of facts stated herein can be used as basis for my disqualification.

SIGNED THIS DAY OF ________________________ at _______________________________________________.

Date Place

_________________________________________
PRINTED NAME AND SIGNATURE OF NOMINEE

IX. CERTIFICATION BY THE NOMINATOR

I CERTIFY THAT ________________________________________ HAS UNDERGONE PRE-SCREENING

(Name of Nominee)

BY THE DEPARMENT AND IS HEREBY NOMINATED FOR THE RCC LEADERSHIP AWARD 2020.

_____________________________
Signature over Printed name

_______________________ ___________________________________
Date Signed Official Designation

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