University of Virginia Counselor Nomination Form
Thank you for completing this nomination form; please remember to submit it no later than Friday, December 14, 2018.
Student Name *
Your answer
Date of Birth (please change the year if you use the drop down calendar) *
MM
/
DD
/
YYYY
Student's Street Address *
Your answer
Student's City, State and Zipcode *
Your answer
Student's Email Address *
Your answer
Race or Ethnicity (optional)
Your answer
Academic Performance *
Weak
Strong
Personal Character *
Weak
Strong
Leadership Abilities *
Weak
Strong
Commitment to Service *
Weak
Strong
Extracurricular Involvement *
Weak
Strong
In the space below, please provide any additional information that may help us assess the student's talents and abilities.
Your answer
I am nominating this student for consideration for the following award(s): *
Check as many as apply.
Required
Counselor's Name: *
Your answer
High School: *
Your answer
School CEEB #: *
Your answer
School Address: *
Your answer
Phone Number: *
Your answer
Email *
Your answer
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