The Jane Goodall Youth Leadership Nomination Submission Form
2010 Jane Goodall’s Roots & Shoots Global Leadership Award
Nomination Form
Please complete the following form (including both Nominator and Nominee portions together) and email it to roots-shoots@janegoodall.org
, or mail a printed copy to:
Roots & Shoots-USA National Office
Attn: Roots & Shoots - USA the Jane Goodall Institute
4245 North Fairfax Drive, Suite 600
Arlington, VA 22203
Nominator
First Name
Last Name
Organization/School
Title/Position
Email Address
Phone Number(s)
Day: Evening: Mobile:
Address
Street: Apt./Ste.:
City: State: Zip:
Nominee
First Name
Last Name
Date of Birth
Roots & Shoots Group Name
Email Address
Phone Number(s)
Day: Evening: Mobile:
Address
Street: Apt./Ste.:
City: State: Zip:
Name of Parent(s)/Legal Guardian
First: Last:
Parent(s)/Legal Guardian Contact Information
Phone Number: Email Address:
Questions to be Completed by Nominator
Please answer these questions honestly and to the best of your ability. Feel free to attach newspaper articles, project descriptions, pictures or any other material that will help answer these questions. All materials sent with the application will become property of the Jane Goodall Institute. Answers should be between 200 – 400 words.
You may attach a separate sheet to fully answer each question.
Please describe your relationship with the person you are nominating for the leadership award? How long have you known him or her? In what capacity have you worked with this person?
Why do you wish to nominate this individual? Please list any projects, events or other initiatives this person has led, coordinated or participated in.
Questions to be Completed by the Nominee
Please answer these questions honestly and to the best of your ability. Feel free to attach newspaper articles, project descriptions, pictures or any other material that will help answer these questions. All materials sent with the application will become property of the Jane Goodall Institute. Answers should be between 200 – 400 words.
You may attach a separate sheet to fully answer each question.
What qualities do you possess that make you a good candidate for the Jane Goodall
Youth Leadership Award?
Please describe any service activities or initiatives you have been actively involved with that benefited people, animals or the environment, highlighting any leadership roles or responsibilities you assumed. Discuss how you plan to continue your work in the future.
