Nomination Form for School Nurse of the Year SNOA Annual Award

NAME: SCHOOL DISTRICT: HOME ADDRESS:

E-MAIL: SCHOOL NAME: SCHOOL ADDRESS:

HOME PHONE:

WORK PHONE:

FAX NUMBER:

• Years of School Nursing Experience: • Years as a members of SNOA (2 years minimum required): • School Nurse Certification YES NO     • Five most recent continuing education classes of workshops (please attach certificate of attendance for each class): 1. 2. 3. 4. 5.

• Committees Served on in your school district during the last 5 years: • Health Services Department:     • District Wide Committees:     • Professional Organization Memberships:         • Attach three letters of recommendation from peers, parents, or other professionals. • Please tell us in 200 words or less why you are nominating the above individual:

Nominee's Signature: Nomination Sponsor Signature:

Date: Date:

Return Application To: Mary Freeland, 7020 W. Ocotillo, Glendale, AZ 85303 Application due October 1

Awards will be presented at Summer Conference