Educator Nomination Form

Educator Primary Nomination - Old

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Educator Information

(* Required)

Educator's First and Last Name*
First Last
Educator's Phone Number*
Educator's Address
Street Address Address Line 2 City State ZIP Code
Educator's Email*
Name of Project/Activity to which criteria will apply*
School Affiliation (can be private or public within Lake Oswego)
Is a Second Educator Being Nominated for the Same Project/Activity?
Second Educator's First and Last Name*
First Last
Second Educator's Phone Number*
Second Educator's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Second Educator's Email*

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Position*
Length of Time in Position*
Brief description of Educator's project/activity/service that demonstrates Service above Self. The project, service, activity should occur above and beyond the person’s job description*
Length of time Educator 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 Educator?)

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Describe how the five "Service Above Self" criteria apply to the Educator's project, activity, or service.
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 Educator initiate the project/activity/service or show personal initiative in performing it?
• How much time does the Educator invest in the project/activity/service?
• Does the project/activity/service meet a school need? How?
• Does the project/activity/service meet a community need? How?
• How is the Educator an inspirational leader who engenders support of other involved stakeholders?
2. Inspires others to improve, grow and/or attain educational excellence
Suggested details to consider:
• How does the Educator create a positive learning environment that impacts others?
• How does the project/activity/service involve analysis, evaluation, problem solving and decision making?
• How does the project/activity/service demonstrate and engender high educational ideals?
• How did students/beneficiaries learn new skills through their access to the project/activity/service?
3. Builds a strong sense of confidence, competence and/or community awareness in others
Suggested details to consider:
• How did the project/activity/service encourage mutual trust and empowerment?
• How was the Educator effective in communication, organization, creativity?
• How did the Educator motivate citizenship in others?
4. Generates measurable impacts that leave a positive legacy
Suggested details to consider:
• Has the project/activity/service been a measurable success (if possible, provide metrics to illustrate numbers)?
• How many people were involved in participating in or completing the project/activity/service?
• How will it be measured in the future?
• How did the Educator’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 community and school-related activities is the Educator involved in?
• What is the Educator’s role in these activities?
• If the Educator has a significant or leadership role in these activities, please describe that role/ involvement.
What else should we know about your Educator

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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 Educator. 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/.
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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Educator Primary Nomination - Old

Step 1 of 5 -

Educator Information

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