Educator of the Year 2011 Nomination Form

(Must Be Typed)

Teacher Name: Home Address: Home City/State/Zip Code: Home Phone: District: School: Cell Phone: School Phone:

Subject Taught (if applicable): Position Held: Grade Level: Email Address: Years in Professional Education: Favorite Song:

PROFESSIONAL PREPARATION: (If available) Dates Institution Degrees and Honors

I. II. III. IV. V.

A letter of nomination. A biographical sketch. A statement of nominees teaching philosophy. A chronological list of all teaching experience/history, if available. Other documents and materials that have direct bearing on the nominees teaching achievements for the students with AD/HD.

VI. VII. IX.

Any relevant supportive documentation. Nominees professional contributions to education in the field of AD/HD. A headshot (i.e. yearbook picture) of nominee must be included.