Please complete the following questionnaire completely and in detail as your answers will be reviewed by the selection committee and will determine your level of leadership and involvement on campus.
Due to the large number of applicants, please be concise and clear in the essay portion and limit your answers to no more than four paragraphs per question.
**Please note that you cannot save this form, it may be helpful to prepare your answers before you start the questionnaire**
The nominee questionnaire form is due by 8:00am Monday March 14, 2011. If you have any questions, please email or call Dana Mallett in the Alumni Affairs office at 715.346.3813
NOMINEE FORM
Personal Information
Phonetic spelling of last name (ex: Adams = Add-ums):
Student ID Number
Local Address/City/State/Zip:
Email:
Parent(s) Name (for acknowledgement during ceremony):
Home or Permanent Address/City/State/Zip:
Name of Spouse (if applicable) (for acknowledgement during ceremony):
Name(s) of children (if applicable) (for acknowledgement during ceremony):
Education
Major area(s) of study:
Minor area(s) of study:
Cumulative Grade Point Average (GPA) :
Anticipated date of graduation : May 2011August 2011
1) Please list the campus activities in which you VOLUNTEERED while in college (no abbreviations please):
2) Please list the campus activities you participated in that were PAID POSITIONS while in college (no abbreviations please):
3) List any honors or recognitions you have received while in college (e.g., scholarships, awards, articles published in journals or magazines, etc.)
4) List any additional responsibilities or accomplishments which could be considered by the Selection Committee (Teaching Assistant, tutoring, Orientation Leader, Residence Hall staff, community or hometown activities while in college, etc)
5) For the purpose of this award, the university has been using a broad definition of leadership put forth by Warren Bennis and Burt Nanus who suggest that leaders are people who:
How do you feel your involvement on campus meets or exceeds this definition? Please be specific in your explanation as your answers will be used as a determining factor of your involvement.
6) We define campus/community service as the unselfish giving of oneself in the serving of common good of our campus/community, and the quality of an individual’s response to membership or citizenship through their campus/community contributions.
In what ways do you feel your campus/community service meets or exceeds this definition?
7) We define personal growth as the degree to which students have attended workshops, participated in seminars, demonstrated mature decision-making/problem solving abilities, and participated in campus/community experiences which demand graduated amounts of personal or professional sophistication.
How would you say your personal growth experiences on this campus meet or exceed this definition?
If chosen as a recipient of the Chancellor’s Leadership Award or the Albertson Medallion Award, how would you like your name inscribed on the medallion? (ex: Sue Ann Miller or Sue A. Miller)
If selected as a recipient of the Chancellor’s Leadership Award or the Albertson Medallion Award, I grant permission to release the information I have provided on the questionnaire to the committee to review.
Thank you for your time in submitting your questionnaire for the Chancellor’s Leadership Award and Albertson Medallion Award. If you have any questions, please email or call Dana Mallett in the Alumni Affairs office at 715.346.3813.
