Hampton Roads Young Achievers Nomination Form

Hampton Roads Young Achievers is designed to
encourage and applaud young people who exhibit excellent character, community involvement, wise use
of leisure time and a commitment to achieving their personal best. Sponsored by WAVY-TV and Langley Federal Credit Union.

Hampton Roads Young Achievers nominations are accepted each school year from August 15th until May 1st.
Students who live in southeastern Virginia or northeastern North Carolina, and who are in grades eight through 12
are eligible. Utilize the online form below to nominate a student.

You may also send the form via regular mail, the address is:
Hampton Roads Young Achievers WAVY-TV Public Affairs Department
300 Wavy Street Portsmouth, VA 23704

You may also request a nomination form by calling 757-393-1010.

Nominee Information:

Date:

Current Grade Level:

Nominee's Name:

Address:

City, State & Zip

Parent or Guardian:

Address:

City, State & Zip

Telephone:

School Name:

Address:

City, State & Zip

Telephone:

In order for the judges of Hampton Roads Young Achievers to make an equal assessment of nominees, please describe the following:

List Community Involvement: (include dates involved)

List School-related Extracurricular Activities: (include dates involved)

Character and Personal Best: Explain how the student's activities build character, create a positive attitude, provide discipline or enhance self-determination.

Student Statement: Nominees need to describe in their own words how their activities help them to become responsible citizens and how they have a positive effect on their school and community.

References: Please supply information on two other persons that can speak to the qualifications of this nominee:

Name:

Telephone:

Address:

Occupation:

Name:

Telephone:

Address:

Occupation:

Person Making Nomination:

Name:

Telephone:

Address:

Email: