Leadership in Action Nomination | Civics Matters Arizona

Civics Matters Summit Leadership in Action Nomination Form

Please complete this form if you wish to nominate an emerging or experienced civic leader to participate in the Leadership in Action open networking experience. This portion of the Summit is designed to give students the opportunity to meet young leaders, Civics Matters alumni, public servants, community advocates, and professionals working in both traditional and nontraditional civic roles. Through informal conversations, students can learn how others became involved, explore different forms of leadership, and identify ways to begin making a difference now. Educators, students, organizations, and community members may nominate emerging or experienced leaders to participate. Student leaders and young adults are especially encouraged.

Nominator Name(Required)

First Last

Nominator Email(Required)

Nominator Phone Number(Required)

Country Phone Number

Nominator Date of Birth(Required)

Why we ask for your date of birth: We collect this information to comply with privacy requirements, including COPPA, and to ensure that children under 13 do not submit personal information through this form.

Parental Consent(Required)

By submitting this form you acknowledge that you are the parent and/or legal guardian of the child to be registered in the form above, and that you have read, understand and agree to be bound by our Website Terms of Use and Privacy Policy.

Accept Parental Consent

Are you nominating yourself for the Leadership in Action segment?(Required)

Note: Have more than one person to nominate? Please submit a separate form for each nominee.

Yes, I want to participate in the Leadership in Action segment

No, I am nominating someone else to participate

Nominee Name(Required)

First Last

Nominee Email(Required)

Nominee Phone Number(Required)

Country Phone Number

How do you know the nominee?(Required)

Personally

Professionally

Other

Please explain why you believe the nominee is an ideal fit for the Leadership in Action open networking session.(Required)

Please provide any relevant online references that speak to the nominee's civic leadership(Required)

Examples: LinkedIn profile, news articles, interviews, etc.

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