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Fifth Grade Challenge Student Nomination Form
Part A: School Information
Required
School Name
*
Required
Principal Name
*
Required
Phone
*
Required
Please enter a valid email address with the format youraddress@yourdomain.
Email
*
Required
Teacher Name
*
Required
Please enter a valid email address with the format youraddress@yourdomain.
Email
*
Required
My application is supported by my principal.
*
Required
My application is supported by my teacher.
*
Part B: Student Nominee
Required
Student Name
*
Required
Address
*
Required
City/State/Zip
*
Required
Gender
Male
Female
*
Required
Race
*
Required
Student's Hobbies
*
Part C: Student Nominee Parent Information
Required
Parent Name 1
*
Required
Cell Phone #
*
Required
Please enter a valid email address with the format youraddress@yourdomain.
Email
*
Required
Parent Name 2
*
Required
Cell Phone #
*
Required
Please enter a valid email address with the format youraddress@yourdomain.
Email
*
Part D: Please write a question based on your favorite subject in Curriculum 2.0. Your question might be selected for inclusion in the production.
Required
*
Part E: Student Nominee Statement: Why do you want to be in the 2015 Fifth Grade Challenge?
Required
*
Part F: In the space below, write the name of a celebrity that you would like for us to invite to play the game?
Required
*
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