Safe Routes to School Programs

Achievement Award for Public Officials

Eligible individuals are advocates and spokespeople for healthy living. Furthermore, through their public role they must have demonstrated a commitment to policies that support physical education, active communities and programs that support and encourage physical activity.

Note: For the written portion of this nomination form (located at the bottom), it's recommended that you type your response in a separate word document first and copy/paste your response into the text box area. This will prevent the loss of data should you need more time to fill out this form.

Your Information *First Name: M.I.: *Last Name: *Address: *City: *State: *Zip:

*Phone Number: *Email: *Relationship to Nominee:
I'm nominating myself

Nominee's Information *First Name: M.I.: *Last Name: *Address: *City: *State: *Zip: *County: *Phone: *Email: *Age: Race: (Optional) Optional:

*Selection Criteria:

Each response limited to 500 words

Describe the nominated individual's commitment to creating policies that support physical education and active communities. Be sure to include any specific bills or policies the individual has supported. (10 points)

Describe how this public official has served as a role model for healthy living. (5 points)

Describe how this individual educates or advocates for health and wellness in his/her community. (5 points)

Provide background information about the catalyst for the individual’s support of health and wellness and how his/her work has inspired others. (5 points)