For a printable copy of this form, click here.
*ALL FIELDS ARE REQUIRED
Name of Student being nominated:
E-mail address of Nominee:
Telephone Number of Nominee :(i.e. xxx-xxx-xxxx)
Your Name:
Your E-mail address:
Your phone number:(i.e. xxx-xxx-xxxx)
Your Relationship to the Nominee:
Organization Student is being nominated for:
Position they hold in this organization:
Please describe how this student displayed outstanding leadership skills in the past 30 days (A detailed description of the student’s contribution will help the selection committee):
How did the organization benefit from this?
Approximately how many hours did the nominee put forth while doing this?
Qualities that describe this student leader:
Other reasons why you think this student should be selected to be the Student Leader of the Month?
