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Fifth Grade Challenge Student Nomination Form
Part A: School Information
School Name
*
Principal Name
*
Phone
*
Email
*
Teacher Name
*
Email
*
My application is supported by my principal.
*
My application is supported by my teacher.
*
Part B: Student Nominee
Student Name
*
Address
*
City/State/Zip
*
Gender
Male
Female
*
Race
*
Student's Hobbies
*
Part C: Student Nominee Parent Information
Parent Name 1
*
Cell Phone #
*
Email
*
Parent Name 2
*
Cell Phone #
*
Email
*
Part D: Please write a question based on your favorite subject in Curriculum 2.0. Your question might be selected for inclusion in the production.
*
Part E: Student Nominee Statement: Why do you want to be in the 2015 Fifth Grade Challenge?
*
Part F: In the space below, write the name of a celebrity that you would like for us to invite to play the game?
*
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