Eliza Pickrell Routt Award Application

Eliza Pickrell Routt Award Application

for outstanding voter registration efforts in registering 85% or more eligible high school seniors to vote.
School Name*
Please enter the school name how you would like it to appear on the award.
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county is the school in?*
If the school is in more than one county, please list them here
What school district is the school in?*
Teacher or Administrator

First NameLast Name
Teacher or Administrator Title
Teacher or Administrator Email
example@example.com
Teacher or Administrator Phone Number
Please enter a valid phone number.
Student Leader(s)
Please enter names of all students who worked towards the voter registration goal.
Number of eligible seniors*
Percentage of seniors registered*
How would you like the award presented?*

Our school would like the award mailed, no presentation necessary.Our school would like the award presented at the school by a CDOS staff member.
Please select a date & time for a presentation. We will confirm via email. If necessary, we will reschedule via email.

MonthDayYear
Hour MinutesAM/PM Option
If the above listed Teacher or Administrator is not the best contact to coordinate award delivery, please list the best contact and their email and/or phone number

Best Contact First NameBest Contact Last Name
Best Contact Email
example@example.com
Best Contact Phone Number
Please enter a valid phone number.
The school listed above has registered at least 85% of its eligible seniors as Colorado Voters. They have met the criteria for the Colorado Secretary of State's Eliza Pickrell Routt Award.*

I hereby certify that the information I have provided is correct.
Should be Empty: