Youth Achievement Awards Nomination Form

Award Nominee Criteria

Nominees for this award must meet the following criteria:

· CEO or Regional Director of the agency has authorized (via signature on the nomination form) this child as a nominee from that member agency for this award. Nominees must be currently or formerly in foster care.  Each provider agency is allowed to nominate one child per agency program to receive this award;

· He or she has made extraordinary achievements in the past year by meeting and/or surpassing many of the goals set by the agency, FOR EXAMPLE:

o   He or she has overcome significant challenges.

o   He or she shows concern for others and is kind and courteous in most situations.

o   He or she has made significant academic or career progress in the last year.

o   He or she is involved in a hobby or extra-curricular activity

 Please complete and submit the nomination form below by May 20, 2018.

* 1. Name of Nominee:

* 2. Age of Nominee:

* 3. Name of Nominator:

* 4. Nominator Phone Number:

* 5. Nominator Email Address:

* 6. Nominator Relationship to Nominee:

* 7. Name, email address & phone number of person who will accompany youth to event (if different from Nominator):

* 8. Agency Name and Address


Please use the space below to explain briefly of how the Award Nominee has made extraordinary achievements in the past year by meeting and/or surpassing goals set by the agency.


Please list the youth’s answers to the following questions (these will be on the slide with their name/age, agency’s name):

* 10. What has had the greatest impact on your success?

* 11. What brief (1-2 sentences) “words of wisdom” or advice would you offer to other youth/students like you?


* 12. Electronic Signature of Nominator & Date

* 13. Electronic Signature of CEO or Regional Director & Date

Nomination Deadline is COB on May 20, 2018.  Questions?  Please contact 
Rachel Mygatt at