NAGC – NICHOLAS GREEN DISTINGUISHED STUDENT AWARD
INDIVIDUAL APPLICATION FORM 2007-2008 Student Information
Name ______________________________________
Address _______________________________________________________________________
Telephone number____________________ Age________Grade (at time of selection) ____________
Birth date ____________________ Social Security Number ______________________
Name of parent or guardian _______________________________________________________
Address ______________________________________________________________________
Telephone __________________________ e-mail ____________________________
School name _________________________
School address ________________________________________________________________
Teacher’s name ____________________________________
Name of Person Nominating Student (e-mail confirmation of receipt will be sent here)
Name _______________________________________
Address ______________________________________________________________________
Telephone (day)_______________________________ e-mail _______________________________
Relationship to Nominee __________________________ Other Notification
Is there anyone else that you would like to be notified of this achievement (school principal, teacher)? Please indicate
name and address below:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
__________________________________________
NAGC - NICHOLAS GREEN DISTINGUISHED STUDENT AWARD
2007 – 2008 RELEASE FORM
I hereby give the National Association for Gifted Children (NAGC) permission to use my son or daughter’s photo and
composition, submitted in connection with the NAGC – Nicholas Green Distinguished Student Award, in any publicity or
announcements NAGC may make about the award or the award winners.
I further grant permission to NAGC to use my son or daughter’s name, school name, city, and state in any publicity or
announcement that uses his or her photo or composition, and to make any necessary edits to the length of the
composition.
I understand that neither I, nor my son or daughter, will receive any remuneration in connection with this permission. I
also understand that the photo and composition will not be returned to me.
Date________________ Parent Signature___________________________________
Parent Name (please print) ______________________________________________
Address __________________________________________________________________________________
City/State/Zip ______________________________________________________________________________
Phone (day) _______________________ e-mail __________________________________
Relationship to Student Award Nominee ______________________________________________
Name of Student Nominee ______________________________________
Student’s Social Security Number (necessary to purchase Bond) ______________________________________