Nominee Qualifications for the Eastern District Honor Award

Nominee Qualifications for the Eastern District Honor Award

1. SHAPE America Membership: The nominee shall have beena memberof SHAPE America foraminimumof10yearsincluding the year he/she is considered for the award.
   Former SHAPE Americamembers whohaveretiredfromtheprofessionare exemptfromthisrequirement.
2. Education: A bachelor's and master's degree are preferred, or substantial evidence of continued professional development in the fields of health, physical education, recreation or dance.
3. Character: Ethical behavior consistent with the accepted ideals of the profession.
4. Service: Contributions made primarily through professional associations at the state, district or national levels, with evidence of leadership in a least five (5) of the following categories:

1. president or vice president of a SHAPE America district
2. president or officer ofSHAPE Americaor Council
3. member of SHAPE America Board of Directors
4. president or officer of a state association
5. chair or member of at least three committees or program sections at state, district or national level
6. president, officer or chair of organization in the profession
7. community or professional service relating to the profession
8. committee membership or leadership of note at place of employment
9. presentations, workshops or addresses before educational and/or civic groups in health, physical education, recreation or dance given in person, via radio, television or the Internet
10. evidence of published research or professional articles or book chapters in health, Applicationform,supportlettersandaphotomust be submittedelectronicallyby November 1to: Ellen Benham at

Eastern DistrictHonor AwardApplication

Please submit all information electronically, including completed form, support letters, and a photo to:

Ellen Benham - , no later than November 1.

Please complete thisformby entering theinformation in the provided spaces.

Saveyour completed form andsend it asan attachment.

Date:______

Name ofNominee:______

Professional Title: ______

Address(W): ______

______

Phone (W):______

FAX (W): ______

E-mail Address (W): ______

Home Address: ______

Home Phone:______

Home E-mail Address: ______

Home FAX: ______

Nominee’s SHAPE America membership number and expirationdate:______

Nominee’s SHAPE Americamembership dates (mustbe current member and havehad10 years of membership): ______

Professional Preparation:

Institution and Year:______

Degree:______

Institution and Year:______

Degree:______

Institution and Year:______

Degree:______

Other:______

Nameof Biographer(Nominator):______

Professional Title: ______

Address (W): ______

Phone(W): ______

E-mail address(W): ______

FAX(W): ______

Professional Experience:

Position: ______

Institution/company/organization: ______

Dates of employment in chronological order (mostrecentfirst):

Position: ______

Institution/Company/Organization: ______

Dates: ______

Position: ______

Institution/Company/Organization: ______

Dates: ______

Position: ______

Institution/Company/Organization: ______

Dates: ______

Position: ______

Institution/Company/Organization: ______

Dates: ______

ProfessionalService:

Nominee mustfulfillatleast five qualifications. Please provide specific informationinappropriate categories:

President or VicePresidentof District Association noteoffices and year(s)

Office: ______

Year(S): ______

President or Officerofa SHAPE America - National Associationor Council (specify organization(s) or council(s) andyear(s))

Office: ______

Associationor Council: ______
Year(s): ______

Member of SHAPE AmericaBoard of Directors (identifypositionand year(s))

Office: ______

Year(s): ______

President or OfficerofState Association (identify state, position(s),year(s))

Office: ______

State: ______

Association: ______

Year(s): ______

Chair or Member of Committeesand/or Sections (atleast 3)

Chair or Member: ______

Committee/Section: ______

State/District/National: ______

Year(s): ______

President, Officer or ChairofOrganizationin theProfessionYear(s)

Office: ______

Organization: ______

Year(s): ______

Communityor Professional Service Relating to the Profession

Service: ______

Description: ______

Organization: ______

Year(s): ______

Committee MembershiporLeadership of NoteatPlace ofEmployment include role, employment location, committee title,and date.

Role: ______

Committee/Leadership: ______

Placeof Employment: ______

Year(s): ______

Presentations, Workshop, or Addresses (Please list title,event,anddate).

Selectnomorethansix(6) of the mostrecentor important

Title: ______

Event: ______

Year: ______

PublishedResearchandProfessional Articles or BookChapters

Select no morethan six (6) ofthemostrecentorimportant

Title; ______

Journal: ______

Year: ______

Books authored or Co-authored (include title,publisher,and date)

Select no morethan five(5) of themostrecentor important

Title: ______

Publisher: ______

Year” ______

Other Professional Honors Received (specify name of honor or award,granting organization, and date) Selectnomorethan six(6)

Honor or Award: ______

Granting Organization: ______

Year: ______

Other OutstandingContributionsorUnusualService to theProfession which hasaffected itsphilosophyorpracticesnot includedpreviously (provide specificinformation to describe the contribution orservice)

Contribution/Service: ______

Description: ______

TwoSupportLetters - Include twolettersofsupport

(biographer/nominator may not writeone ofthe support letters) with the application

•One letter fromsomeone at thenominee’s workplace and

•A secondletterfromanother colleague outsidetheworkplace. The letters should speaktothe nominee’s leadership,service, and contributionsto SHAPE America or theprofessionatthestate,district, and/ornational levels.

Biographer’s (Nominator’s)Summary Statement and Additional Information This statement further describes the nominee’suniquequalificationsasa recipient ofthe ED Honor Award. Additional attached materials will not beconsidered.

Name andaddressofthenominee’simmediatesupervisor - (department chair, dean, president,principal, supervisor, or other)

Name: ______

Address: ______

Phone: ______

E-mail Address: ______

Signatureof the Biographer (Nominator):______

Nominee’s Photo.

Includea currentpicture of thenomineefor use inthe awards ceremony program

Nominee’s Bio

Include a brief bio of 100 words or less to be read at awards ceremony.