NAGE role model nomination form

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  • 1. Nomination Call for NAGE Role ModelWe are pleased to announce a “Nomination Call for NAGE Role Model” at LakeheadUniversity.The NAGE Role Model Program provides an opportunity for Aboriginal, Metis or Inuitstudents to be recognized for their achievements, leadership and innovation.Role models must be enrolled in full time studies in either the Masters or PHd programat Lakehead University.Two NAGE Role Models will be selected. One will be chosen from a Masters Programand one will be selected from a PHd program. Winners will be announced on February16th, 2012.Who:Anyone can nominate their role model by filling out the nomination form. Students maynominate themselves.When:Nomination deadline is 12:00 PM on Friday, February 3, 2012.How:You can nominate a NAGE Role Model by submitting:  Nomination formPlease send submit form to: ABORIGINAL CULTURAL & SUPPORT SERVICES (ACSS) Attention: NAGE Coordinator, Fay Zoccole Regional Centre – 0002 955 Oliver Road Thunder Bay, Ontario P7B 5E1 Phone: (807) 343-8085 FAX: (807) 346-7757 Email: fzoccole@lakeheadu.ca
  • 2. NAGE Role Model Nomination FormPart A: Nominator and Role Model Information NominatorFull Name: ___________________________________________________________Address: __________________________________________________________________________________________________________________________________Phone: ______________________________ Email: _________________________ My NAGE Role ModelFirst Name: ___________________________ Last name: _____________________Address: __________________________________________________________________________________________________________________________________Phone: ___________________________ Email: ____________________________This student is registered in: (check one) Which course is this student taking?  Masters Program __________________________________  PhD Program Specialization: _____________________Part B: Reason for NominationProvide details of the achievements of your nominee: (Please enter as much detail asyou can to help the judging panel):1. Introduction: Tell us a bit about your Role Model________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  • 3. 2. VOLUNTEER (e.g., Do they work for free at community events? What events andhow often do they volunteer? with Elders? What kind of things do they do? etc.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. HELPFUL (e.g., Do they help others with their work? How do they help others? Dothey treat others with respect and care? etc.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. OVERCOMING ADVERSITY (e.g., Have they lost family members or had setbacksor challenges that they have had to overcome? Did they manage to move on with theirlife in a positive way? How have they overcome their struggles? etc.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. EXCELLENT STUDENT (e.g., What is their level of education? What program arethey taking? Do they work hard for good grades? What kind of academic awards havethey received? etc.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. OTHER IMPACTS (e.g., What other areas have they impacted you or others? Havethey won awards? For what? How are they a role model? How do they contribute toLakehead University? etc.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please feel free to add an additional page to help the judges get to know your nominee better.