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Please confirm that you are 19 years of age or older by checking the following box.    
The girl I would like to nominate is:  
She lives in:  
in the province/territory of:  
She saw a need and with energy, ingenuity and commitment she made a difference.
This is what she did:
(Please include what inspired her, what obstacles she overcame and what resulted from her actions.)
The name of her
parent(s)/guardian(s) are:		  
They have given approval for her to be nominated, and for her name and picture to be used for publicity if she is selected. If selected, a further release form will be required.
Her parents can be reached at:
Telephone:  
Email:  
Address:  
 
City:  
Province/Territory:  
Postal Code:  
The name of the person submitting this nomination is:  
And can be contacted at:
Telephone:  
Email:  
Address:  
 
City:  
Province/Territory:  
Postal Code:  
   
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