Deadline for entries is December 16, 2005 Please fill out the form below. All fields must be filled in to successfully submit the nomination form. Please note: The nomination form below must be completed in conjunction with the nominee. Important information is needed from the nominee to complete the last portion of the application. Please review before submitting nomination form. I would like to nominate the following person as a Hometown Hero: Nominee Information Section Nominee First Name Nominee Last Name Home Address City Zip Email Address Home Phone Work Phone Nominee Community The City of Alamo Heights The City of Balcones Heights The City of Bandera The City of Blanco The City of Bulverde The City of Castle Hills The City of China Grove The City of Cibolo The City of Converse The City of Elmendorf The City of Fair Oaks Ranch The City of Garden Ridge The City of Grey Forest The City of Helotes The City of Hill Country Village The City of Hollywood Park The City of Kirby The City of La Coste The City of Leon Valley The City of Live Oak The City of Marion The City of New Braunfels The City of Olmos Park The City of San Antonio The City of Schertz The City of Seguin The City of Selma The City of Shavano Park The City of Somerset The City of Stockdale The City of Terrell Hills The City of Universal City The City of Windcrest Nominator Information Section: Nominator First Name Nominator Last Name Home Address City Zip Relationship to Nominee Email Address Home Phone Work Phone Hometown Hero Questionaire Please answer the following questions to provide the judges with an understanding of the nominee and his/her work benefiting children. Any personal insight you can provide will help the judges understand your nominee better and the motivation behind his/her efforts. Please limit responses to 500 words per question. 1. Describe the volunteer service the nominee performed toward a specific goal in the local community that had a positive affect on children. 2. Please list any programs or services the nominee has developed and describe its impact on the youth in the community. 3. How has the nominee motivated others to get involved and assist with his/her volunteer efforts? 4. List any association or groups of which the nominee is a member including community, professional, educational, or religious. Please include position held, years of involvement, and any awards received by the nominee for their service. THIS SECTION TO BE COMPLETED BY NOMINEE In the event I am chosen as a Hometown Hero, I designate the following 501 (C)(3) nonprofit organization, which supports youth-related causes to be entered into a random drawing to be held the night of the event. The organization selected shall receive a $2,500 contribution on behalf of Time Warner Cable and The Hometown Heroes Program. Time Warner Cable may, at its sole discretion, redesignate the recipient of the award if the group chosen is not a 501 (C)(3) dedicated youth-related organization. Organization Contact First Name Contact Last Name Address City Zip Phone Number Federal Tax ID# Checking the box below confirms that the information contained in this nomination form is factual and gives permission for publication of the facts.  I agree to attend the Hometown Heroes Award Ceremony hosted by Time Warner Cable and News 9 San Antonio and agree to the use of my name and likeness without compensation in conjunction with the promotion of Hometown Heroes. I Agree Deadline for entries is December 16, 2005 For additional information, contact: Time Warner Cable Hometown Heroes 8434 Gault Lane San Antonio, TX 78209 Phone (210) 828-3086, Extension 36 Fax (210) 805-9458