Nomination Form

(Feel free to use additional space if desired)

Nominee: Phone:

Address:

Nominated by: Phone:

Address:

List the activities the nominee is involved in that enable him or her to impact Huntington County’s youth:

_______________________________________________________________________

In what ways has the nominee been instrumental in reaching the youth of Huntington County?

Please describe the impact that the nominee has had on Huntington County youth.

Number of years working with youth.

Please return to: Youth Services Bureau

1344 Maple Drive

Huntington, IN 46750

Nominations are due November 30, 2011. Recipient will be recognized at the YSB’s Annual Dinner on January 26, 2012.