CLARKSON UNIVERSITY
AWARD FOR INSPIRATIONAL HIGH SCHOOL EDUCATORS
COMMENCEMENT 2016
NOMINATION FORM
Most of us have had a high school teacher, counselor, coach, administrator, or staff member who stands out in our hearts and
memories as a significant influence in our lives. The lessons such outstanding educators teach often go far beyond the subject matter of
their fields. They may instill values and a love of learning that shape our educational and career choices, and guide us well throughout
our adult lives. Clarkson University wishes to recognize a few of the exceptional high school educators who have influenced the lives of
our students. A few former educators of members of the 2016 class will be invited to campus for Commencement Weekend, during
which they will be honored. Selections will be made on the basis of information and insights presented on this nomination.
This form must be returned by Monday, January 18, 2016 to Pat Thompson, Assistant to the Dean of Students, Clarkson University, Box
5570, Potsdam, NY 13699-5570. Telephone 315/268-6620 or email at thomppa@clarkson.edu. Please do NOT notify the educator of
your nomination.
NOMINATION INFORMATION
Clarkson Student’s Name: _________________________________________________________________________________________
Local Address: __________________________________________________________________________________________________
Telephone: ____________________________ Major: __________________________________________________________________
YOUR NOMINEE:
Educator’s Name:________________________________________________________________________________________________
Subject(s) taught/or position held:___________________________________________________________________________________
School’s name and address: ________________________________________________________________________________________
(As completely as you can) ________________________________________________________________________________________
Name of School Superintendent: __________________________________________ Telephone: ________________________________
Does this educator still work at the school: Yes ________ Unsure _______ No* _________
*If No, can you give the educator’s present professional location:
__________________________________________________________
Educator’s home address (if known): ________________________________________________________________________________
________________________________________________________________ Telephone: ____________________________________
To the best of your knowledge, is this educator recognized as an outstanding educator and person of good character by other students
and colleagues? _________ Comments:
_________________________________________________________________________________
______________________________________________________________________________________________________________
In honoring the high school educators who are selected, may we quote from your statements in this nomination?
Yes ____ No ____
Your signature: _________________________________________ Date: ___________________________________________________
Please complete the following sections of the questionnaire in your own words. Submit printed responses to these four questions,
keeping answers clear and to the point.
It is helpful for the selection committee when responses are as specific as possible, reinforcing your praise and comments with real-life
examples that reflect the educator’s qualities and character.
1.
What are the three primary reasons for your choosing this educator to be your nominee?
2.
Describe the ways in which this educator has had a positive impact on your life, including the successes you have enjoyed here
at Clarkson.
3.
Please describe an actual situation in which you remember observing this educator demonstrating characteristics that you feel
are the hallmarks of outstanding educator.
4.
In a brief paragraph, write a “thank you” message to this educator, expressing in a personal way your gratitude for the ways in
which he or she has influenced your life.
THANK YOU FOR YOUR COOPERATION
RETURN BY MONDAY, JANUARY 18, 2016
To:
Pat Thompson
Assistant to the Dean of Students
Box 5570
Clarkson University
Potsdam, NY 13699-5570
or
Email her at thomppa@clarkson.edu