Georgia Department of Education

Division for Special Education Services and Supports

2017 Recognition Program Awards Application

Due March 6, 2017

This year the Georgia Department of Education is honoring Georgia High School Seniors with Disabilities who have had academic and/or extracurricular accomplishments, as shown by:

  1. Earning a scholarship to a four-year, two-year, or vocational technical school;
  2. Earning a Regular Education Diploma with outstanding extracurricular involvement in school/community;
  3. Earning a Special Education Diploma with transition to career education and/or employment

Please complete all of the following information. Type or print LEGIBLY.

Completed applications should be sent to:

Frank Nesbit, Division for Special Education Services,

1870 Twin Towers East, Atlanta, Georgia 30334.

Incomplete applications cannot be accepted.

Date of Application: / School District: / GLRS Location:
Student’s Full Name: / Phonetic Pronunciation:
Student’s Preferred Name:
Special Education Category of Disability: / Age:
Parent(s) Name:
Parent(s) Address:
CityZipcode:
Phone Day: / Phone Evening: / E-mail Address:
High School’s Name and Address (including 9 digit zipcode): / School Phone:
School’s Name: / School Principal:
Street Address: / Special Education Director:
City: / Zip Code: / Superintendent:
State Board of Education Member:
Congressional District:
NOTE: To locate the correct Congressional District go to. Enter the address of the school and search. The results should display which Congressional District to enter above.
School System Contact During the Summer:
Name: / Title:
Summer Phone: / Summer FAX: / Summer E-mail Address:
Please complete the application on the following pages for the nominated student.
  1. The student has shown exemplary qualities, and should be considered for the following categories:
(Please check all boxes that apply and circle the applicable descriptor.)
Scholarship to:
 / A 4-year institution
 / A 2-year institution
 / A Technical School
Regular Education Diploma with outstanding achievement and
extracurricular involvement in school/community, and transitioning to:
 / A college/university;
 / A technical school; and/or
 / Full-time employment
Special Education Diploma with transition to:
 / Career education; and/or
 / Full-time employment
  1. Please provide the details of the student’s achievements: Including specific scholarship and college/university/technical school information, academic achievements, awards, grade point average, extracurricular activities, life skills, and any other accomplishments of the student as it relates to his/her academic program during high school.

  1. Please complete any of the appropriate sections below by describing how this student has shown other skills and achievements. Please provide copies of any examples of his/her work, documentation, and/or letters supporting your nomination.

This student has shown innovative use(s) of technology by:
This student’s exemplary participation in sports has been demonstrated by:
This student’s exemplary participation in the Arts (creative writing, visual arts, and/or performing arts) has been demonstrated by:
This student’s ability to be successful in social/peer relationships/organizations/clubs/community activities has been demonstrated by:
Other achievements of the student that should be considered are demonstrated by:
What will the student do post-graduation?

Student:School District:

Congressional District:GLRS Location:Page 1 of 3