PLEASE TYPE
ATHLETIC HALL OF
FAME ASSOCIATION
NOMINATION FORM
[Eligibility for nomination
cannot be granted for a minimum of ten years following graduation of the
class.]
NAME:_______________________________________ DATE SUBMITTED:_________________
CATEGORY
(Pick One): _______ STUDENT ATHLETE
_______COACH or
ADMINISTRATOR
ADDRESS:________________________________________________________________________
________________________________________________________________________
YEAR
OF GRADUATION FROM
PHONE:_________________________
EMAIL:_________________________________________
DATE
OF BIRTH: ________________ DATE
DECEASED (IF APPLICABLE): _____________
IF
DECEASED, ACCEPTOR OF NOMINATION:
______________________________________
ACCEPTOR’S
RELATIONSHIP TO DECEASED:______________________________________
ACCEPTOR’S
PHONE:______________________ EMAIL:_______________________________
High School Athletic Accomplishments/ Awards/ Honors
1. Varsity Sport ____________________________________
Dates Played/ Coached______________
Honors:
2. Varsity Sport ____________________________________
Dates Played/ Coached______________
Honors:
3. Varsity Sport ____________________________________
Dates Played/ Coached______________
Honors:
Post-Secondary Athletic Accomplishments/ Awards/ Honors
1. Sport ____________________________________
Dates Played/ Coached______________
Honors:
2. Sport ____________________________________
Dates Played/ Coached______________
Honors:
3. Sport ____________________________________
Dates Played/ Coached______________
Honors:
ADDITIONAL COMMENTS
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I hereby state that the information submitted on this form is factual.
Print Name Signature
**If a resume is prepared, please attach to this document**
An
application/ nomination will remain active for three years. If a nominee is not inducted, the nomination
will automatically become inactive. It
is the responsibility of the nominator to update applications and re-submit
forms if needed.
Kindly return
applications to:
Butler Athletics
Butler Senior High
School
120 Campus Lane
Butler, PA 16001