2019 C5LA Teacher Nomination Form
To be completed by teacher, counselor or school staff member. Please be as mindful as possible about how you answer. Complete the write-in section as thoroughly as you can with useful information about the student. Provided is a list of the criteria for participants to be considered for C5 Los Angeles. Note that a range in these factors is considered.

-8th grader
-High potential & promise
-Demonstrates leadership
-Under-resourced & in need support
-3.0 GPA
-Positive attitude & good behavior at school
-Desire to be successful with high personal motivation
-Consistent and reliable adult support
-Involved in extracurricular activities
-First-generation college student
-Qualify for Free/Reduced-Cost Lunch
-Growing up in a risk-filled environment
-Single-parent family or family that cannot provide support
-Can adjust to camp and being away from home
-Can meet physical requirements
-Not likely to get distracted by other interests and commitments
-Recognized for achievements and contributions
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Email *
Name of Nominee *
School *
Email Address of Nominee *
Name of person completing this nomination *
Position (i.e. teacher, counselor, etc.) *
How long have you known this nominee? *
On  a scale of 1 to 10, rate how well you know this nominee. "10" means extremely well. *
Please complete the chart below using the following rubric:                                                                 "Outstanding" = Top 5% when compared to his or her peers; "Better than average" = Top 25%; "Average" = Student's performance is in the middle; "Below average" = Student is less prepared than most others' *
Outstanding
Better than average
Average
Below average
Unknown
Dependability: Accepts responsibility; follows through with commitments; arrives on time and when expected; trustworthy.
Cooperation: Good team member; works well with peers; accepts direction & listens to instructions; sense of fairness.
Leadership Skills: Expresses opinions diplomatically; able to provide positive direction & motive others.
Judgement: Makes good decisions; thinks things through; understands how his/her actions impact others.
Communication Skills: Listens & speaks well; expresses thoughts clearly; participates in discussions; insightful.
Relationships with peers: Relates well to males and females; accepts differences in opinion, style, & appearance.
Stability/Maturity: Manages emotions well; appropriate sense of humor; can focus on tasks at hand; non-disruptive.
Attitude: Respect for people and things; optimistic; manageable even when having a "bad" day; open to new things.
Give us your opinion of the nominee by selecting the appropriate box: *
Strongly Agree
Agree
Disagree
Strongly Disagree
This student enjoys learning and values education.
This student is prepared to stay away from home for 4 weeks.
This student is prepared to manage the physical and mental demands of camp.
This student will take C5 seriously.
This student will make C5 a priority.
This student's family will be supportive of his/her involvement.
When compared to hundreds of nominees, this student is a deserving candidate.
Why should this nominee be considered for C5LA? *
Please list personal accomplishments and academic honors the nominee has achieved: *
Describe the nominee's involvement in school and the surrounding community including volunteer service and extracurricular involvement: *
Please describe any opportunities for growth for the nominee: *
Thank you for taking time to complete this nomination. By doing so, you are recognizing a young person as a positive contributor in your community. In addition, for those young persons who are accepted by C5LA, you are introducing them to the opportunity of a lifetime!                                                                             Please initial and date below: *
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