Student Nomination Form

Section One -
Student (Nominee) Information

I. Basic Information

Student's First Name:
Student's Last Name:
Student's School
Student's Grade:
Student's Date of Birth:

II. Demographic Information (optional)

Race(s) (choose all that apply):
American Indian or
Alaska Native
Native Hawaiian or
Other Pacific Islander
Asian White
Black or
African American

III. Parent/Guardian Name and Contact Information

Parent/Guardian Name:
Relationship to Student:
Street Address:
Zip Code:
Primary Phone:
Alternate Phone:

Section Two -
School District Representative (Nominator) Information

Representative's Name:
Representative's Title:
Representative's School:
Representative's Email:
Representative's Phone:

Section Three -
Acknowledgement of Statement of Eligibility

"I hereby certify that, to the best of my knowledge, the above-listed student qualifies for free or reduced lunch, as determined by Salem-Keizer Public Schools. I also certify that the legal parent or guardian of the above-listed student has granted me permission to submit the student's name for nomination to Children's Technology Foundation Northwest."

By entering my initials and today's date in the box below, I indicate my agreement with the above statement and submit this student for consideration to Children's Technology Foundation Northwest.

Initials and Date:

About this Form...

The Student Nomination Form is provided to assist school district personnel in quickly and efficiently recommending students at their school or institution to be recipients of a future CTFNW computer donation.

To nominate a student, simply fill out the fields of the form on the left side of your screen, then press the submit button. Your student's information will be electronically delivered to CTFNW and will be reviewed for accuracy and completeness.

After review, a CTFNW representative will contact you to further discuss the nomination and award process.