Contact your DOD or Joe Ethier with any questions.

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1. Please select your state:

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2. Date:

Date

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3. Nominee Name:

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4. Club Affiliation

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5. Length of Board Membership:

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6. Nominee Company

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7. Nominee Work Title:

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8. Nominator Name:

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9. Nominator Title:

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10. Board Participation:  Select the person's attendance percentage of regular board meetings.

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11. Committee Service:  The individual has served on the following committees (select all that apply)

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12. Leadership:  List any offices held by the nominated individual.  Include name of office and dates held.

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13. Resource Development:  The individual is responsible for financial contributions to their Boys & Girls Club at the following level:

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14. Service to Area Council:  The individual has served the Area Council in the following capacity (select all that apply)

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15. BGCA Education Training:  The individual participated in the following (select all that apply)

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16. Impact on Boys & Girls Club:  Please describe the immediate impact of this individual's involvement with your Boys & Girls Club.

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17. Community Relations:  Please list other service groups or agencies with which the nominee is involved.  How have these affiliations helped your Boys & Girls Club?

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18. Additional Information:  Please list any other pertinent information you would like to share concerning the nominee's Club service, awards received, personal or family information, college attended, etc.

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19. Supporting Documentation:  Please upload any supporting documents here:

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