APPLE Award

Appalachian Leaders in Education

Student or Student Group

2012 Nomination Form

Purpose: Forward in the Fifth created this award to recognize a student or group of students who have had a positive impact on school involvement, educational success or supporting a desire to stay in school.

Eligibility: Nominee(s) must be a current student of an accredited school (P-12), college, university or certificate program whose primary residence is in Forward in the Fifth’s 42 county service area. An established student club (e.g. FBLA, FCCLA, HOSA, etc.) may also be nominated.

Nominee Information

Name or Student 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: Click here to 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: 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 accomplishment to increase educational attainment. ___ Reading/Language Arts	___ College/Career Readiness ___ Math	___ School Safety ___ Science	___ Counseling ___ Social Studies	___ Policy Development ___ Art/Humanities	___ Employment Opportunities ___ Other Academic subject:	___ Literacy __________________________ ___ Attendance/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 student/group has gone above and beyond normal 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 peer support contribute to the success of this practice/project?

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

Why is this student/student group 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