Dearborn Public Schools Impact Award
2015 Nomination Form
Deadline for submitting nominations: April 24, 2015.
Name of employee being nominated: ____________________________________________
(The nominee must have been employed by the Dearborn Public Schools for at
least 3 years.)
Work location of nominee: _____________________________________________________
Job title of nominee, if available: ________________________________________________
Name of person submitting nomination: __________________________________________
Please check all that apply regarding the person submitting the Impact award
nomination.
 Secondary Student (please list school) _______________________________________
 Parent
 District Staff Member (please list work location / job title):
______________________
Phone: _________________________________
Email: __________________________________
Nomination:
In 250 words or less please describe how the Dearborn Public Schools staff
member you are nominating:
1. Consistently demonstrates at least one of the Dearborn Public School
District’s Core Values.
2. How through their work they create a better experience for students, families
or colleagues in the Dearborn Public School District.
3. That they are consistently personable, professional and polite in the daily
performance of their job.
(Please use additional pages as needed.)