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LDA of Indiana State Award On-Line Nomination Form

Nominations are now closed for the Academic Scholarship Award and the "Student of the Year "for Junior/Middle
School and High School Levels. Nominations for the Elementary Level "Student of the Year" are still being accepted.

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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) Students Contact Information

Name:

Full Address with Zip Code:

Home Phone with Area Code:

Email Address:

Grade in 07/08 school year - i.e.6th grade: Does the student have a Sp Ed IEP Plan or 504 Plan for his/her LD or ADHD:

Name of Indiana School:

Name of School District/Corporation:

Name of Parent(s):

4) Your Contact Information

Name:

Title or Position:

Email Address:

Full Address with Zip Code:

Home Phone with Area Code:

5) Tell us why you feel this student should be considered for this Nomination:
Examples: Tell us how their LD or ADHD affects their academic and social/home life, How do they face new experiences,
demonstrate perseverance, self-advocacy skills, or serve as a role model for their peers or other people in their lives.
Writing Hint: You can write this section off-line and then "copy & paste" the text into the box below.

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 Bar to send in your nomination.
After you click on the submit bar, you will see a copy of your nomination.
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