Cedar Grove Elementary School – Ben Carson Application Form
Please complete the following nomination application to the best of your ability. Please print/type so we can
read all of your information clearly.
Student Name:
Teacher:
Parent Name:
Email:
Address:
Telephone:
Marking
Period 1
Grades
Service
Email:
Subject
Grade
Reading
Writing
Mathematics
Science
Social Studies
Please list all community service performed in the last two years
Dates
Why did you choose this community service?
Essay Question: Please address the following question to the best of your ability.
A role model is a person who has the qualities that we would like to have and who inspires us to be a
better person. Who is your role model? Please explain why you have chosen this person and how
this person has inspired you.
Please use a separate document/sheet of paper to respond to this question and attach it to this application.
The information provided on this application is true and accurate to the best of my knowledge.
Student Signature:
Parent Signature:
Please feel free to add any further information on the back/on an additional attached document.