Teacher/Student/Employee Nomination Form

Date*

Date

Name of Nominee*

First NameLast Name

Nominee*

School employeeSpouse of an employeeChild of an employeeStudent

Nominee Status*

Currently employedEmployee on medical leaveRetired

School/workplace in Chaves County*

How do you know this nominee?*

How long have you known this nominee?*

Cancer Diagnosis*

Date of Diagnosis (or estimated, if known)

Is this nominee currently receiving cancer treatment?*

YesNoUnknown

Type of cancer treatment*

ChemotherapyRadiationMaintenance MedicationUnknown

Describe to the best of your ability the nominee's personal story.*

Share how this nominee impacts students/peers.*

Provide any additional information about how the nominee supports the community, church, or other volunteer roles.*

Is the nominee aware that he/she is being nominated?

Your Name*

First NameLast Name

Your Phone Number*

Your Email*

Submit any printed forms to:

Roswell Independent School District

300 N. Kentucky, Roswell, NM 88201

All nomination forms must be submitted by April 1st or October 1st of each year for consideration.

ARM Foundation Nomination Form