Youth Civic Award Nominations | U.S. House of Representatives

Youth Civic Engagement Nomination Form

Your Name*

Your Phone Number* () -

Your Email*

Relationship to Nominee*

Nominee Name*

Nominee Phone Number* () -

Nominee Email*

Nominee Mailing Address*

Street 1 Street 2 City State Zip

Description of Outstanding Community Service*

Parent/Guardian Names*

Parent/Guardian Phone Number () -

Parent/Guardian Email