Leadership Awards Youth Nomination Form

1. NOMINEE INFORMATION:
Nominee Name:*
Home Phone:
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Cell Phone:
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Work Phone:
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E-mail:
Employer:
Title:
Tribal Affiliation:
Mailing Address:
Is the nominee aware of this nomination?
2. YOUR CONTACT INFORMATION:
Your Name:*
Your Home Phone:
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Your Cell Phone:
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Your Work Phone:
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Your Mailing Address:
Your E-mail:
3. What is your affiliation with the nominee?*
4. Please specify a nomination category:*

5. Why do you believe this individual deserves to be recognized? Describe how this individual has demonstrated commitment to the American Indian Community.

Please be sure to address each of the following statements:

a.) How has the nominee assisted the American Indian community by developing or showing leadership in self or school-based clubs and activities? (maximum 3000 characters)
b.) How has the nominee demonstrated excellence in education, creativity and initiative? (maximum 2000 characters)
c.) Describe how the student has demonstrated a strong representation of the American Indian community through after school and weekend clubs / activities both culturally and non-culturally based. (maximum 5000 characters)
d.) How has the nominee provided valuable service by devoting time and energy to improve the quality of life for others in the American Indian community? (maximum 3000 characters)
e.) Describe how the nominee has proved themselves as a leader among peers an in affecting positive change in school and in the community. (maximum 3000 characters)
f.) Please state the student’s GPA. (maximum 250 characters)

6. Include two (2) references that are non-family members or friends of the family should the committee need to follow up for additional information. (E.g. Teacher, Coach, Pastor, Tutor, etc…)

Note: Additional helpful attachments include a Bio and/or a Resume.

Reference #1 Name:
Reference #1 Home Phone:
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Reference #1 Cell Phone:
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Reference #1 Work Phone:
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Reference #1 E-mail:
Reference #1 Employer:
Reference #1 Title:
Reference #1 Mailing Address:
Reference #2 Name:
Reference #2 Home Phone:
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Reference #2 Cell Phone:
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Reference #2 Work Phone:
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Reference #2 E-mail:
Reference #2 Employer:
Reference #2 Title:
Reference #2 Mailing Address:
Please upload any additional files to support your nominee (ie., Resume, Bio, Letter of Recommendation)
NOTE: This is NOT required.
Upload file(s):