University of Virginia Counselor Nomination Form
Thank you for completing this nomination form; please remember to submit it no later than Friday, December 15, 2017.
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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