Age: Date of Birth:
IMPORTANT: If Female, please list dress size:
Nominee's Condition (For example: Spina Bifida, Cancer, Craniofacial, Cerebral Palsy, Other):
Your name and affiliation to the Nominee (parent, relative, teacher, counselor, other):
IMPORTANT:Prior to submitting this nomination form, please read the "Guidelines to Nominating a Superstar" document!
I have read the Nomination Guidelines.
I, , parent/guardian of the following minor: do hereby authorize the participation of the above named child in Night of Superstars: I do further hereby release and hold free from any and all liability any and all participants of Night of Superstars, including Night of Superstars, Superstar Events, Inc., Supporters of Children’s Charities, Singles Charities Council and their officers, board members, chairmen, directors, employees, volunteers, sponsors and contractors. I specifically release all associated sponsors & vendors from any and all liability arising from the transportation of the above named minors & chaperones to and from the outing, from their presence there and from their participation in Night of Superstars. It is my understanding that reasonable care and supervision of all children will be provided by the sponsors of this event. Individually and on behalf of the child. I understand participation in the event carries risks of injury and accident and I assume such risks and their consequences freely. I further understand that should an illness or accident occur with the child, I will assume full responsibility for the payment of all related medical expenses.
I also permit all photos and videos taken of me or my child at this event, including those submitted by me to be used by Night of Superstars, Superstar Events, Inc., Supporters of Children’s Charities, sponsors and all other participating organizations as needed for marketing/publicity purposes now or in the future. Also, by signing this nomination form, I agree that I have read and fully understand the “Guidelines to Nominating a Superstar” document.
I consent to the use of my name entered below as my electronic signature. I further agree that my electronic signature on this form is as valid as if I signed the document in writing.
Electronic Signature (Please type your full name):
Our Superstar Selection Committee makes their decisions based upon a nominee's abilities. Especially, those abilities that directly defy their physical and/or intellectual challenges! So please answer all the questions below that apply to your Superstar nominee!
IMPORTANT: A Superstar nominee needs to excel in only one of the following areas in order to be considered to participate: Academics, Athletics/Extracurricular Activities, the Arts & Community Service. Please understand that due to time constraints of the gala, our Superstar Selection Committee is only able to select 10 nominees to participate.
1. Please briefly describe your Superstar’s condition and the challenges associated with his/her condition:
2. Does your Superstar excel academically? YesNo If so, what is his/her current GPA?
Despite his/her GPA, please explain how he/she might be excelling despite his/her current condition (physically or intellectually).
3. Please list any sports or extracurricular activities your Superstar is involved with (includes cheerleading, Special Olympics, Miracle League, etc.). Let us know how their ability in any particular activity defies their physical or intellectual challenges.
4. Please list any arts that your Superstar might be involved in (dance, art, music, etc.):
5. Let us know about your Superstar's level of community involvement. Is your Superstar involved with community projects or volunteer programs at a hospital, church, or other nonprofit organization? Or does your Superstar have their own nonprofit organization?:
6. Please let us know of any organizations your Superstar is involved with (Boy/Girl Scouts, etc.):
7. Please list any awards your Superstar might have received in the following areas within the past 3 years: Academics, Athletics/Extracurricular Activities, The Arts, Community Service. Please add a brief description on each:
8. Does your Superstar have a career in mind? If yes, please list career goals: