Form C

5th District Winner

Name of School District_______________________________________________________________

Name of School_____________________________________________________________________

FIFTH GRADE DISTRICT WINNER'S NAME

___________________________________________________________________

(Please type the winner's first name, middle initial and last name as it should appear on the plaque)

Please complete the following information for your student

Name of Student_____________________________________________________________________

Name of Parent______________________________________________________________________

Family's Address_____________________________________________________________________

Home Phone________________________________________________________________________

Name of Classroom Teacher____________________________________________________________

Student's Signature____________________________________________________________________

Parent's Signature_____________________________________________________________________