Youth Achievement Award Smart Kids with Learning Disabilities 2024 Fred J. Epstein Youth Achievement Award Application Submit by January 16, 2024 NomineeNominee Name(Required) Name Nominee Age(Required) Parent/Guardian Name(Required) Name Parent/Guardian Email(Required) Parent/Guardian Mobile Phone(Required)Nominee Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Nominee Phone Number(Required)Nominee Email(Required) Documented Learning Disability or ADHD(Required) School Currently Attending(Required) School Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Upload Documents(Required)Upload Documented Proof of the nominee’s LD or ADHD (e.g., 2-3 pages from an IEP). Drop files here or Select files Max. file size: 2 GB. Upload Your Personal Statement(Required)Upload nominee’s Personal Statement describing how they have dealt with the challenges associated with the learning disability or ADHD (up to 2 pages). Drop files here or Select files Max. file size: 2 GB. Upload Your Photo(Required)Upload a recent High-Resolution Photo of the nominee. (jpeg, png, pdf) Drop files here or Select files Max. file size: 2 GB. Upload Supporting MaterialsUpload Supporting Materials (i.e., certificates, awards) that demonstrate the nominee’s achievement. (Optional) Drop files here or Select files Max. file size: 2 GB. NominatorNominator's Name(Required) Name Relationship to Nominee(Required) Nominator's Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Nominator's Phone(Required)Nominator's Email(Required) Upload Nominator's Statement(Required)Upload the nominator’s written description of the nominee’s learning disability or ADHD and achievement, including the impact the achievement has had on the nominee and others. Drop files here or Select files Max. file size: 2 GB. Consent by Parent/Guardian(Required)I authorize release of the information stated below on behalf of: Name of Child Legal Relationship to Child(Required) I hereby authorize Smart Kids with Learning Disabilities (SKLD) to use and release information contained in the application for the Fred J. Epstein Youth Achievement Award that I am submitting on behalf of the child named above. I understand that SKLD may release information including the Nominee’s name, likeness, and narrative information (but not including details of the diagnosis, IEP plan or other supporting documentation) in its newsletter(s), promotional and other written and visual material, presentations and outreach efforts. (Please note that SKLD will not release telephone numbers, email and street addresses or fax numbers without seeking your prior permission.) Additionally, if the child nominated above wins the 2024 Award or Special Recognition Award, I agree to attend the award ceremony with the child (who will be expected to give a brief 3 minute acceptance speech, and to submit a 2-3 minute video). Transportation costs and hotel accommodations will be provided by Smart Kids for the child and parents.(Required)Sign AboveDate(Required) MM slash DD slash YYYY 59865Δ
