Page Title

LDA of Indiana State Award On-Line Nomination Form

Individuals may be nominated for more than one category. Please complete a separate entry for each category.

Thank you for completing this on-line nomination form.
If your nominee is selected, we will notify you by email. Award winners will be sent a letter by postal mail.
All nominations not selected will receive an acknowledgement card.

Please review the information above and then click on the Submit button to send in your nomination.
After you click on the submit bar, you will see a copy of your nomination.
To return to our website, click on your back button or arrow.

Helping Families & Professionals Connect with Information, Training and Resource Since 1969

1) This Nomination is for:

2) This is an:

If this person has already been nominated by someone else select "Additional Letter of Recommendation,"
add their full name, then skip down and complete Sections 4 & 5.

3) Nominees Contact Information

Name:

Full Address with Zip Code:

Home Phone with Area Code:

Email Address:

4) Complete this section for Parent of the Year Nominees

Name of Indiana School:

Name of School District/Corporation:

5) Complete this section for Teacher or Administrator of the Year Nominees

Name of Indiana School:

Name of School District/Corporation:

Supervisors Name:

6) Complete this section for Outstanding Service Award Nominees

Name of Indiana Business, Organization, School, Agency or Individual:

7) Your Contact Information

Name:

Title or Position:

Email Address:

Full Address with Zip Code:

Home Phone with Area Code:

8) Tell us why you feel this person should be considered for this Nomination:
Please give specific examples of how this person goes above and beyond their duties in helping students with LD or ADHD,
serves as a role model, or provides support services to families, co-workers or community.
Writing Hint: You can write this section off-line and then "copy & paste" the text into the box below