PLEASE TYPE

BUTLER AREA SCHOOL DISTRICT

ATHLETIC HALL OF FAME ASSOCIATION

NOMINATION FORM

[Eligibility for nomination cannot be granted for a minimum of ten years following graduation of the class.]

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NAME:_______________________________________  DATE SUBMITTED:_________________

 

CATEGORY (Pick One):   _______                STUDENT ATHLETE        

_______COACH or ADMINISTRATOR

 

ADDRESS:________________________________________________________________________

 

                      ________________________________________________________________________

 

YEAR OF GRADUATION FROM BUTLER (IF APPLICABLE):_____________________________

 

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