Ivy Rose Award Nomination Form

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Please complete and submit this form no later than November 29, 2021 at 5:00 p.m.

Email *

Date *

YYYY

Date *

YYYY

Name of Person Submitting This Form: *

Category *

Name of Organization / Individual / Non-Traditional Student *

If you are nominating an organization: Name of CEO / Director / President

Nominee's Address *

Nominee's Email *

Nominee's Phone Number *

Target Population of Organization or Individual

Planned Target Population of Non-Traditional Student

Year Organization Was Founded / Year Individual Began Serving the Brooklyn Community / Year Nominee Returned to School *

(A) Describe Organization’s / Individual's Activities -- OR-- (B) Discuss Nominee's Degree or Professional Certification Program and Service Goals *

How has this organization / individual provided exemplary service to the Brooklyn community in the category referenced above? -- OR -- (B) Has this non-traditional student provided exemplary service to the Brooklyn community? If so, please describe. If not, please discuss the student's plan(s) to be of service to the Brooklyn community. *

How would this grant enable the organization / individual / non-traditional student to be an agent of change in Brooklyn (and beyond)? *

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