Page 2 - Parent Press

Florida Diagnostic & Learning Resources System (FDLRS)-Parent Services Hillsborough County Public Schools (HCPS) 13th Annual EXCELLENCE IN ACTION AWARDS

T
Instructions:

his award is for individuals who have made a difference in the life of a student with special needs. Parents, caregivers or students (only) can submit nominations for anyone within the educational setting or community groups/volunteers who work with Hillsborough County Public School (HCPS) students receiving Exceptional Student Education (ESE) Services.

E xc e l l e nc e i n Act i o n Awa rd s N o mi na t i o n Fo r m
Please use 1 (one) form per Nominee. Please Complete Entire Form (Front and Back pages). It is very important that accurate contact information is provided so that your nominee can be notified.

T he N o mi n at io n F o rm i s A va il ab le O n lin e ! It s F a st an d E a s y !
Nominations may also be submitted by mail to Karen Luddington, FDLRS, 4210 Bay Villa Ave,, Tampa, FL 33611 or by fax to (813) 837-7702. Questions? Call FDLRS, Parent Services: (813) 837-7732. Deadline: March 30, 2012 2 50 wo rd M ax im um .

Reason for Nomination: Please Print Clearly - Feel Free To Use A Separate Sheet .

P L E A S E COM P L ET E FR O N T A ND B AC K P AG E S

2012 Excellence in Action Awards Nomination Category (select one per form)
ESE Teachers: Pre-K through Elementary School Middle School High School through Graduation Middle School High School - 22 yrs General Education Teachers /Inclusion: Pre-K through Elementary School

Administrative: (*ex: District Resource Teacher, Principal, Asst. Principal, etc.) *Specify: Therapist: Support Staff: Speech Aides OT Health Driver PT Food Service Attendant (Bus Number: *(Other) Specify: Media ) Clerical Custodial Supervisor

Transportation Staff:

Other / Community Agencies (*example: crossing guards, sports & recreation, etc.) *Specify: Volunteers: Peer buddies Parents *(Other) Specify:

Nominee Contact information: (including name of school/work location if different from the school your child is attending this year). Nominee Name: School / Work Address: School / Work Phone: Nominator Information: Name: Address: Email Address: Phone/Cell Number: Student Information: Student Name: Age: School: Class/Program: Select your child's disability category. (Please select all that apply) Autism Spectrum Disorder (ASD) Specific Learning Disability (SLD) Deaf or Hard of Hearing Speech and Language Developmental Delay Visually Impaired Emotional/Behavioral Disability Gifted Other (Specify) Intellectual Disability (InD or EMH/TMH/SPMH) Physically/Other Health/Orthopedically Impaired/Traumatic Brain Injury (PI/OHI/OI/TBI)
P L E A S E COM P L ET E FR O N T A ND B AC K P AG E S