APPLE Award

Appalachian Leaders in Education

Educator

2012 Nomination Form

Purpose: Forward in the Fifth created this award to highlight efforts to engage students, families and community leaders to promote increased educational attainment and life-long learning.

Eligibility: Nominee must be a full or part-time employee of an accredited school, school district, early childhood center, postsecondary institution or area technology center. Employees include faculty and teachers, administrators, and service or support staff (e.g., classroom assistants, cafeteria, bus drivers, family resource/youth service center, custodians) or any other school personnel. A coalition or co-op representing more than one school or district may also be nominated. Nominees must work within educational facilities located in the Forward in the Fifth service area. A group comprised of parents and educators would not be eligible, however they could be nominated for a parent/parent group award.

Nominee Information

Nominee Name: Click here to enter text. Title/Position: Click here to enter text.

Address: Click here to enter text.	City: Click here to enter text.

State: Zip: Click here to enter text.

Phone: Click here to enter text. E-mail: Click here to enter text.

School/District/Institution: Click here to enter text.

Nominee is a(n): Choose an item.

Person Submitting Nomination

Name: Click here to enter text.	Position/Title: Click here to enter text.

Address: Click here to enter text. City: Click here to enter text. State: Click here to enter text. Zip: Click here to enter text.

Phone: Click here to enter text. Relation to Nominee: Click here to enter text.

I agree that everything submitted in this application is, to the best of my knowledge, true and accurate. I acknowledge this information becomes the property of Forward in the Fifth and will be held in strict confidence.

Nominator Signature: ______________________________________________Date: ________________

Nominator Printed Name: ___________________________________________

Identify no more than two of the following areas in which the nominee has exhibited exceptional characteristics and accomplishments to increase educational attainment. ____ Reading/Language Arts	____ College/Career Readiness ____ Math	____ School Safety ____ Science	____ Counseling ____ Social Studies	____ Policy Development ____ Arts/Humanities	____ Employment Opportunities ____ Other Academic Subject: ______________________	____ Literacy ____ Attendance and Dropout Prevention	____ Assessment ____ Behavior	____ Other Areas: _________________	____ Health & Wellness

Please note that additional sheets of paper may be used to submit this nomination. Be sure to include the entire form

to ensure eligibility.

Briefly outline the educational challenge being met. Why was this issue identified and how is it impacting education in your community?

Describe the nominee’s involvement and how this person has gone above and beyond normal job responsibilities to increase educational success for all. (Please include the intended audience(s), steps taken and outcomes).

How has the nominee used creativity, innovation and/or leadership to have a significant, positive impact in advancing education in his/her area of influence?

In what ways did teamwork, written plans or collegial support contribute to the success of this practice?

Describe the extent to which this activity or work can be or has been expanded to impact more individuals within the community or region?

Why is this person the most deserving recipient of the AppLE Educator Award?

Is there anything else you would like to say about this individual or group?

NOTE: The project may not have reached full implementation and/or achieved final outcomes, but must demonstrate some measurable educational success.

Applications should be submitted by March 31, 2012. Finalists will be selected and notified of their nomination. Awards will be announced in May during a special event.

All nomination information should be submitted via mail or email (no phone or fax submissions will be accepted) to:

Forward in the Fifth

2292 S. Highway 27

Somerset, KY 42501

ATTN: Rhonda Lawson

rlawson@centertech.com

(606)677-6000