Civitas Award Essay Contest Submission Form

Name: _______________________

Essay Number: _______________

Address: _____________________

Date Received: _______________

Phone: ______________________
Email: ________________________

School (please check one)

_____ Howell High School
_____ Kensington Woods
_____ Northbridge Academy
_____ Homeschooled

Please turn this form in, along with your completed essay, to Gigi Jackson in the
Howell High School Guidance Office no later than 3:00pm on Friday, May 3rd, 2013.

Detach the bottom portion and return to the student

Essay Number: ________
Received: _______________________
Date: __________
Initials: ____________