The Admiral Jefferson Student Community Service Award

The Admiral Jefferson Student Community Service Award is given to a student who has made significant contributions to his/her community and has shown outstanding civic responsibility.

On a separate piece of paper state why you feel this student is deserving of this award. Do not exceed 1 side of an 81/2x11 sheet, no less than 12 point.

Please fill out the following application to nominate your special student.

Nominee’s name_________________________________________________________

Address________________________________________________________________

Phone Number__________________________________________________________

Selections criteria (please check all that apply)

• Student is in 9th____ 10th____ 11th____12th ____ grade
• Student is a PTA member (not required)
• Student is from a PTA school (not required)

Student Attends_______________________________________________________

PTA Unit Name________________________________________________________

School Name__________________________________________________________

Address_______________________________________________________________

Nominator (for notification purposes)

Name_________________________________________________________________

Address_______________________________________________________________

Phone Number__________________________________________________________

HAWAII STATE PARENT, TEACHER, STUDENT ASSOCIATION

P. O. Box 22878
Honolulu, Hawaii 96823-2878
Phone (808) 593-2042
Email: info@hawaiiptsa.org

Award will be presented at Hawaii State PTSA’s Annual Convention each year.

Award funded by the Hawaii State PTSA Honorary Lifetime Membership Award.