E.C. McTavish Award Recipient Information Form

As soon as the selection committee has made its selection, neatly fill in and submit this form to the District Office by __________________________. Please ensure that the information about the award recipient is neatly/clearly printed in dark ink. Upon receipt of this page, the District Office will send out information regarding having the portrait taken and invitations to the Awards Dinner.

School: ___________________________________________________________________

Having taken into consideration the criteria for this award, the Selection Committee of the above-named school hereby nominates_____________________________________, presently completing his/her final, graduating year, for the E.C. McTavish Award.

SIGNED: ________________________________________________

Chairperson, Selection Committee

Selection Committee Chairperson: ________________________________________________________________

Members of Selection Committee: ________________________________________________________________

Recipient’s Full Name (Underline Name Commonly Used):________________________________________________

Recipient’s Address:_______________________________________________________________________________

Recipient’s Telephone Number:____________________________________________

The following information is requested for contact purposes at a later date.

Name(s) of Parent(s) / Guardian(s):___________________________________________________________________

Address (if different from that of the recipient):_________________________________________________________

Telephone (if different from that of the recipient):___________________________

Fax (659-2421) this form to the attention of Laurie Lafraniere at the District Office by __________________________.

The deadline for the script and photos is Thursday March 31, 2005.