Fairfax County Athletic Council Neighborhood and Community Services

Fairfax County Athletic Council
Neighborhood and Community Services
Champions of Character Awards
Nomination Form
Nominee Information
Nomination Type:
o Female Athlete (youth)
o Male Athlete (youth)
o Youth Sports Coach
o Parent
o Adult Athlete
Name: _________________________________________________________________________________
Sport:
Team/Organization:
_
Street Address:
_
City:
State:
Telephone (day):
_
ZIP:
_
Telephone (evening):
Email address:
Please check the Fairfax County magisterial district in which the nominee lives or coaches:
(You can verify an address's district online using the "My Neighborhood" feature at www.fairfaxcounty.gov.)
o Braddock
o Dranesville
o Hunter Mill
o Lee
o Mt. Vernon
o Providence
o Springfield
o Sully
o Mason
Please attach a narrative of one page or less explaining why the nominee deserves to win a Champions of
Character Award and how the nominee meets the award criteria.
Nominator Information
Name: _________________________________________________________________________________
Street Address:
_
City:
State:
Telephone (day): ________________________________
ZIP:
Telephone (evening):
_
_
Email address:
I verify that the individual nominated herein has performed as described. Selection committee members may contact me
for verification of this nomination.
Nominator's signature
Mail To:
Date
Champions of Character Awards
Fairfax County NCS- Athletic Services
12011 Government Center Parkway, 10th Floor
Fairfax, VA 22035-1115
Or Fax To:
703-324-5546
Fairfax County is committed to nondiscrimination on the basis of disability in all county programs, services and activities.
Reasonable accommodations will be provided upon request. For more information, call 703-324-4600, TTY 711.
November 2014
www.fairfaxcounty.gov/ncs
A Fairfax County, Va., publication