Nominee   Nominated by  
  First Name:*
   First Name:*
  
  Last Name:*
   Last Name:*
  
  Address:*
   Address:*
  
  City:*
   City:*
  
  State:*
   State:*
  
  Zip:*
   Zip:*
  
  Telephone Number:*
   Telephone Number:*
  
  E-mail Address:
   E-mail Address:
  
  Date of Birth:**   Relationship to Nominee:
  
  Nominee's Chosen Charity:**    
  		 
 
  What does the nominee do to serve Louisiana children?*
  
 
  Did the nominee initiate new programs or activities
and use new methods to solve problems?*
  
 
  Has the activity or service provided by the nominee produced
positive changes and provided examples for other groups?*
  
 
  What results has the nominee produced?*
  
 
  What amount of time does the nominee devote to the activity or service?*
  
 
  Was the nominee active, not a figurehead?*
  
 
  Has the nominee overcome unusual challenges, such as limited
resources, public perceptions of the problem or a personal disability?*