Youth Awards Nomination Form

* Required Fields

NOTE: You will need to provide a narrative (up to 200 words) and upload at least one reference letter in the last section of this form. Make sure you have these items ready before starting this form.

Select Award Category *

Young Citizen of Excellence - Age 12 and Under

Young Citizen of Excellence - Age 13 through 15

Young Citizen of Excellence - Age 16 through 21 (up to 24 for youth with intellectual or developmental disabilities)

The Gary Mervis Youth Team Service Award

Willie W. Lightfoot Youth Advocate (An adult advocate for Youth)

Nominee must be a Monroe County resident!

Nominee Information

Nominee First name*

Nominee Last name*

Phonetic spelling*

Address line 1 (street #, street name)*

Address line 2 (apt. #, suite, etc.)

City*

State*

Zip code*

Daytime Phone #*

Home Phone #*

Email*

Alternate Email - If above is school email, please provide alternate/personal email

Date of Birth*

School (if applicable)

Parent/Guardian Information

If nominee is under 18 please also provide parent/guardian address and contact information.

Is nominee under 18? *

YES NO

Nominator Information

Your First name*

Your Last name*

Organization (if applicable)

Address line 1 (street #, street name)*

Address line 2 (apt. #, suite, etc.)

City*

State*

Zip code*

Phone #*

Email*

Narrative & Reference Letters

Please provide a narrative to support your nomination. Narrative must be no more than 200 words and nominees must meet all selection criteria to be eligible for consideration. To assist in your efforts, we recommend that you be sure to answer the following questions:

How has this individual demonstrated a commitment to the community and Monroe County?
What values does the nominee promote or encourage while working with youth, peers, or others?
In what additional volunteer activities has the nominee participated?

Narrative*

At least one letter of reference needs to be signed by persons attesting to the nominee's services. Include contact information, as they may be contacted for more information regarding the nominee. Uploaded files must include the name of nominee.

Use the button below to attach reference letters *

Upload Reference Letters

Allowed file types: .pdf, .doc, .docx. Max file size: 5mb.

No files uploaded yet

Decisions made by the selection committee are final. Any questions can be directed to [email protected]

Monroe County, NY Adam J. Bello · County Executive

Youth Awards Nomination Form