Instructions: 1) I need to give a favorite quote 2) 50 words or less define leadership from a 17 year-old high school student 3) In 250 words or less, describe how one of my volunteer experiences benefited myself and others. This is the list of two of the volunteer experiences I thought would be best for essay topic Sunday Bible School “ 3 years thru Kindergarten Nursing Home Bingo “ helped residents with Bingo STUDENT NOMINATION FORM To be eligible for the ExCEL Award, students must: 1. be a junior in high school 2. make satisfactory progress toward graduation requirements 3. participate in a League-sponsored fine arts and/or athletic activity 4. hold a leadership position in their school 5. work voluntarily in their community 6. meet MSHSL General Eligibility Requirements (Bylaw 206) INSTRUCTIONS Type all information and answer all questions in the space provided. Handwritten applications will not be accepted. Addendums will not be accepted Please provide all information requested! Do not use acronyms or abbreviations Complete one form for each student (ONE BOY AND ONE GIRL) nominated from your school Include with each nominee’s form: One-page letter of recommendation written by a school staff member (see form provided). Student essay (see form provided) One wallet-size photo of student “ DO NOT staple or paper clip picture to this form. Please include the student name and school on all photos Return nomination form(s) to the MSHSL ExCEL, 2100 Freeway Blvd., Brooklyn Center, MN 55430, postmarked no later than December 14, 2012 Winners will be notified of their selection via League website on February 1, 2013 STUDENT/SCHOOL INFORMATION MSHSL Administrative Region Class A or AA Student’s Name Alissa Mae Stueve School Name Clinton-Graceville-Beardsley School Street Address 712 West Third Street Graceville 56240 P.O. Box City Zip School Phone Number 320 748-7233 Fax Number 320 748-7159 Principal’s Name Larry A. Mischke Email: Athletic Director’s Name Mike Piechowski Email: Was the student a participant in a school safety patrol program in elementary school? Yes __x__ No ____ Student’s Parent(s)/Guardian(s) Terry and Deb Stueve Student’s Home Address 6710 County Road 4 Dumont 56236 P.O. Box City Zip Home Telephone Number 320 760-4499 Home Town Newspaper And Address The Northern Star Newspaper Telephone Number 320 325-5152 Fax Number 320 325-5280 Newspaper Email Address [email protected]’s Name Mike Piechowski Email Title Activities/Athletic Director Nomination Checklist This nomination becomes complete and valid only when you have submitted: nomination form student photo “ DO NOT staple to this form student essay letter of recommendation PARTICIPATION IN INTERSCHOLASTIC ACTIVITIES (* = FALL ACTIVITIES ONLY) MSHSL ATHLETIC ACTIVITIES Grade Awards/honors, records, outstanding (list sport once w/awards) 9 10 11* performances, leadership roles, etc. Volleyball X X X Junior Varsity X Varsity X All Conference; Most Valuable Player; Most Kills Girls Basketball X X Junior Varsity X Varsity X All Conference Honorable Mention Varsity Track X Team Conference Champions 4 x 800 X 1st Place 4 x 400 X 1st Place 800 Meter X 2nd Place Discus X 3rd Place Softball Varsity X (* = Fall Activities Only) FINE ARTS ACTIVITIES Grade wk/mo/yr Awards/honors, records, (list activity once w/awards) 9 10 11* HOURS outstanding performances, leadership roles etc. Senior High Band X X X 3 yr 3 mo Clarinet Solo X X 2 years Excellent Large Group X X 2 years Excellent Jazz Band X 1 year Small Group “ Saxaphone X 1 year Excellent Pep Band X X X 1 yr 3 mo GENERAL CONTRIBUTIONS TO SCHOOL (* = FALL ACTIVITIES ONLY) Grade wk/mo/yr Activity 9 10 11* HOURS Offices held, awards/honors, leadership roles, etc. Honor Roll (Indicate A or B) œA X X X Rank #2 œA Honor Role X 4 quarters œA Honor Role X 4 quarters œA Honor Role X 1st Qrt Class Officer X 1 year Vice President Student Council X X 1 yr 3 mo Sports Concessions X X X 2 yr 1 mo Football and Boys Basketball VOLUNTEER COMMUNITY SERVICE (* = FALL ACTIVITIES ONLY) Total Hours Grand Grade Total Activity 9 10 11* Hours Offices held, awards/honors, leadership roles, etc. Church Fall Dinner X X X 16 Ditch Clean-up X X 4 Sunday Bible School X X X 18 Spring Fling X X 8 Graceville Women’s Turkey Bingo X 2 Santa Days X 2 Nursing Home Bingo X X 8 Nursing Home Christmas X 2 GRAND TOTAL HOURS 70 PRINCIPAL CERTIFICATION The student named on this nomination form is currently a high school junior, has been enrolled in high school for the last five semesters, and is designated to represent our school as its ExCEL student winner. Principal’s Signature Date sr:g:ex.fm nomination “ table 11/30/2012 ExCEL Student Essay Name Alissa Mae Stueve School Clinton-Graceville-Beardsley Schools 1. Please give us your favorite quote: 2. In 50 words or less, provide us with your definition of Leadership: _________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 3. In 250 words or less, please choose one volunteer experience listed on your application and describe how the experience benefited yourself and others. The essay must be one-sided, typewritten, and double-spaced on this form. ExCEL Award Letter of Recommendation (written by school staff member) Student (first & last name) Alissa Stueve School Clinton-Graceville-Beardsley Schools Written by (name & title) In 250 words or less, please explain how the student positively influences others. Please be sure to describe the student’s leadership skills. Letter must be one-sided and typewritten on this form. Nomination Form Instructions TYPE ALL INFORMATION AND ANSWER ALL QUESTIONS IN THE SPACE PROVIDED. Complete the nomination form and submit it to the Minnesota State High School League by the date specified on the nomination form. Please list all of the activities in which the student is involved. Below are sample activities you may list on the nomination form. Do not use acronyms or abbreviations. Indicate the number of hours involved in each activity per week, per month, or per year (i.e. 10/wk). Include only those activities that require eight or more hours per week, per month, or per year. When completing the ExCEL nomination form please consider the following: Athletic Activities List each MSHSL athletic activity in which the student participates. Please include the following information: Team captain All-conference honors All city/metro honors All-tournament teams Number of years on team School/team awards Team academic awards Team member or manager Fine Arts Activities (School/Community) Any involvement in state, section, sub-section, school or community-sponsored activities such as instrumental/vocal music, drama, debate, speech, or visual arts. Write œclass in the œhours column if the activity is part of your course work. Band (includes marching, jazz, and pep) Choir Orchestra Debate Speech One Act Play Visual Arts Lead/major role in play/musical Student director of a play/musical Soloists First chair or section leader in music Best of Site awards Participation in select music groups (e.g. show choir, jazz band) Participation in one or more fine arts activity MN Youth Orchestra Number of years in activity General Contributions to School: This category includes non-League-sponsored activities, which may include, but are not limited to, the activities listed below. Write œclass in the œhours column if the activity is part of your course work. Please include length of service and offices/positions held if applicable. Academic Quiz Bowl Academics Decathlon Future Problem Solving Honor Roll Inroads Knowledge Bowl Language Clubs Math League Multi-Cultural Programs/Clubs National Honor Society National Merit Finalist National Merit Semifinalist Odyssey of the Mind Peer Tutoring/Counseling Science Challenge Spotlight on Scholarship Certificates Scholar-athlete awards Upward Bound Other School Activities: Boys/Girls State Government Class officer Future Farmers of America Future Homemakers of America Key Club Mock Trial School musical School newspaper Student Council Yearbook staff Youth in Government Other school activities which require additional time to serving your school and/or student body. Volunteer Community Service Briefly describe the volunteer services in which the student(s) has participated without pay and that require the student to devote non-school time. Indicate the approximate number of hours involved in each activity. Please include only those activities that require eight or more hours per week/per month/per year (i.e. 10/mo). Grand total hours should be converted into hours per year. Community Involvement: Civic, youth, and professional organizations Church involvement Hospital or health services Tutoring/coaching/mentoring Fundraising for a charitable cause Community theater Other community service projects which require non-school time to serving your community (Continued) SAMPLE SAMPLE SAMPLE Nomination Form * = 11th Grade “ List Fall Activities Only MSHSL ATHLETIC ACTIVITIES Grade Awards/honors, records, outstanding (list sport once w/awards) 9 10 11* performances, leadership roles, etc. Soccer X X X 03-04 Lettered Varsity X X Most Improved X Spotlight on Scholarship X X Gold Basketball X X 9th grade/B-squad captain State Tournament X Participant Spotlight on Scholarship X X Gold Track: 4 x 4 relay X X State: 03/Silver; 04/Gold FINE ARTS ACTIVITIES Grade wk/mo/yr Awards/honors, records, (list activity once w/awards) 9 10 11* HOURS outstanding performances, leadership roles, etc. Band, marching, pep X X Class Jazz X X X 10/wk Jazz X X 8/wk 03/Best of Site Award Choir X Class Section leader Ensemble X X 12/mo Fall Play X X 8/wk GENERAL CONTRIBUTIONS TO SCHOOL (* = FALL ACTIVITIES ONLY) Grade wk/mo/yr Activity 9 10 11* HOURS Offices held, awards/honors, leadership roles, etc. Honor Roll (Indicate A or B) A A n/a Academic Quiz Bowl X X National Honor Society X X Peer tutoring X X X 8/week Spanish Club X X X 8/mo 03/Treasurer Student Council X X X Class Officer X 03-04 President Homecoming committee X Target Group X X VOLUNTEER COMMUNITY Total Hours Grand SERVICE Grade Total Activity 9 10 11* Hours Offices held, awards/honors, leadership roles, etc. Church 40/yr 40/yr X 80/yr Nursery work, preschool setup, Sunday School assistant, youth group, church choir Adopt A Highway 8/yr 8/yr 16/yr Meals on Wheels 10/mo X 120/yr+ Youth Soccer Coach 10/wk 10/wk 200/yr (10 week season) Youth Soccer Referee 2/wk 2/wk 2/wk 60/yr (10 week season ) GRAND TOTAL HOURS 168 288 20 476 sr:h:ww:excel:fm nomination “ table rev. 11/30/12