APPLE Award

Appalachian Leaders in Education

Parent/Guardian or Parent/Guardian Group

2012 Nomination Form

Purpose: Forward in the Fifth created this award to highlight the positive impact parents/guardians have on education and to encourage all parents to become involved in whatever way they can.

Eligibility: Nominations for this award include parents, grandparents raising students, foster parents or any other adult with legal responsibility for a child in school (early childhood, K-12, college or certificate program). To be eligible, the parent/guardian must have a child attending a school, college or degree program in, and reside within, the Forward in the Fifth service area.

Nominee Information

Individual’s Name or Parent Group: Click here to enter text.

Address: Click here to enter text.

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

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

School: Click here to enter text. Grade: Click here to enter text.

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: ____________________________________________________________

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

How has nominee contributed to the success of a student, group of students or school over the past 24 months? Check one of the following areas to highlight nominee’s involvement:

___ Recruiting or organizing volunteers for school or school-related activities.

___ Organizing or coordinating learning activities in the classroom, for homework or extra-curricular clubs/teams (what about other out-of-school programs such as before/after school programs, holidays, summer programs, etc.?).

___ Fostering communication that has made a difference in the school community.

___ Securing or coordinating resources for the school community. Examples include coordinating community resources, getting groups to work together, leading fundraising, grant writing, parent training, etc.

___ Participating on school based committees, serving as a representative for the education community or advocating for a policy or system change (e.g. school-based decision making council, school improvement plan, PTA/PTO, etc.).

___ Other (please specify) ______________________________________________________

Describe the specific involvement of the nominee. Include specific audience(s), steps taken, and progress made.

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?

How has this involvement resulted in a change in student success, increased parental involvement or improved community interaction with a school or school district?

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