Citizen Nomination Form

Citizen Primary Nomination

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Citizen Information

(*Required)

Citizen's First and Last Name*
First Last
Citizen's Phone Number*
Citizen's Address
Street Address Address Line 2 City State ZIP Code
Citizen's Email*
School or Community Affiliation (can be private or public within Lake Oswego)
Is a Second Person Being Nominated for the Same Project/Activity?
Second Citizen's First and Last Name*
First Last
Second Citizen's Phone Number*
Second Citizen's Address
Street Address Address Line 2 City State ZIP Code
Second Citizen's Email*

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Brief description of Citizen's project/activity/service that demonstrates Service above Self.*
Position*
Length of time Citizen has been involved with project/activity/service
Is this a new or on-going project/activity/service?
Start date project/activity/service (estimate if needed)
Number of people benefited (estimate if needed)
How did you become familiar with this person's project/activity/service? (What is your connection to the Citizen?)

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Describe how the five "Service Above Self" criteria apply to the Citizen's project or activity.
Respond to all five evaluation criteria if possible. Each criterion contributes to the nominee’s overall score and ranking by the SASEE judges. The questions listed below each criterion are meant to give you ideas to consider in your response. Please do not feel obliged to provide an answer to each question. However, it is helpful if you can provide concrete examples in your responses.
1. Shows initiative and demonstrates selfless conduct toward others:
Suggested details to consider:
• How did the citizen start the project/activity/service or show personal initiative in participating in it?
• How much time does the citizen invest in the project/activity/service?
• Does the project/activity/service meet an educational need? How?
• Does the project/activity/service meet a community need? How?
• How does the citizen demonstrate selfless behavior toward others within this project/activity/service?
2. Inspires others to improve, grow and/or attain educational excellence
Suggested details to consider:
• In what ways does the citizen build an environment that positively impacts others?
• How does the citizen inspire or support others who are impacted by the project/activity/service?
• How does the project/activity/service involve analysis, evaluation, problem solving and decision making?
• What new skills do participants gain through their involvement with the project/activity/service?
3. Builds a strong sense of confidence, competence and/or community awareness in others
Suggested details to consider:
• Within his/her role, what does the citizen do to develop trust and/or promote individual empowerment for other participants or students?
• How did the citizen demonstrate effective communication and organization? • How did the citizen demonstrate creativity?
• How did the citizen encourage social responsibility in others?
• How did the citizen encourage participants to build their own skills?
4. Generates measurable impacts that leave a positive legacy
Suggested details to consider:
• What were the primary goals or objectives of the project/activity/service?
• Based on those goals, has the project/activity/service been a measurable success?
• How many people (estimate) were impacted by the project/activity/service?
• How will the impact of the project/activity/service be measured in years to come?
• How did the citizen’s project/activity/service result in a sustainable model for others to follow?
5. Steady, long-standing, and active participation in community and school related activities
Suggested details to consider:
• What additional education-related activities is the citizen involved in? For how long? In what role(s)?
• Does the citizen play a leadership role in any of those activities?
• What community-based activities is the citizen involved in? For how long? In what role(s)?
• Does the citizen play a leadership role in any of those activities?
What else should we know about your Citizen.

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Nominator Name*
First Last
Nominator Address
Street Address Address Line 2 City State ZIP Code
Nominator Email*
Nominator Phone Number*

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At least one supporting nomination is needed for each Citizen. Primary and supporting nominations are essential to the evaluation rubric used by SASEE judges in scoring and ranking each SASEE nominee. Please contact one or two other individuals familiar with your Nominee and the project/activity / service and establish assurance that they are willing and available to complete the Supporting Nomination Form. This form is available at www.rotarysasee.org/supporting-nomination/. Completed primary & supporting nomination forms are due by 3-1-21.
Who will you be asking for a supporting nomination of your nominee?
Include the name and email of at least one person. If you have more than one person able to provide a supporting nomination, include a name and email for each person.

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Citizen Primary Nomination

Step 1 of 5 -

Citizen Information

Describe how the five "Service Above Self" criteria apply to the Citizen's project or activity.