The following information may also be helpful to review prior to filling out the form:

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1 2014 Nomination Form Please note: Prior to filling out this online form, you may wish to download a version of this form to fill out offline. The 2014 Nomination Form is available in a Word version or as a PDF to view or download. Downloading the Word version may require you to enable content/macros to edit and save the document. Please note that the PDF version will navigate you away from the online form. The College recommends that you draft and review your 750-word essay offline, and then copy and paste the essay into the online form when you are ready to submit the nomination. Please note that rich text- such as bold, italics, or underlining- will not show up in the online form. The following information may also be helpful to review prior to filling out the form: Frequently Asked Questions (FAQs) Nominator/Nominee Focus Area Descriptions (includes nominator employer type/nominee area of accomplishment) For mandatory fields (*) that are not applicable to you, the nominator, or the nominee(s), please write N/A (not applicable) in the space provided. Nominations are due by Friday, November 8, 2013, 11:59 p.m. Central Standard Time Information Regarding You as Nominator: Information regarding you as the individual submitting the nomination: First Name:* Last Name:* Are you affiliated with Grinnell College and, if so, how?:* Grinnell Student (enter class year below) Grinnell Staff Grinnell Faculty Grinnell Alumni (enter class year below) Grinnell Trustee No Affiliation Grinnell Alumni/Student Class Year: Your Title:* Your Organization/Employer:* Your Organization/Employer Website:* Type N/A if your organization or employer does not have a website. Your Responsibility Within Organization or Job Description:* Your Organization Focus Area or Employer Type:* Agriculture, Food

2 Animal Related Arts, Culture, and Media Business Civil and Human Rights Crime, Legal Services Education Environmental Sustainability, Protection, and Conservation Government Health Human Services International Development, Foreign Affairs, and National Security Philanthropy and Volunteerism Public Safety, Disaster Preparedness, and Relief Religion, Spiritual Development Research, Think Tank Social Entrepreneurship Youth Leadership, Development No Focus Area Other (describe below) Please select the focus area which best describes your organization or employer. For a description of the various focus areas or employer types, please view Nominator/Nominee Focus Area Descriptions. If other focus area or employer type, please briefly describe: How May We Contact You? Street Address:* City/Town:* State/Province:* Zip Code/Postal Code:* Country:* Select your country from the drop-down menu on the online nomination form. Phone Number:* Address:* Are you nominating a single individual or two individuals jointly?:* Single Joint Do you know the nominee(s) personally?* Yes No Briefly describe your relationship with the nominee(s). If no relationship, write None :*

3 Is the nominee aware that you are nominating him or her?:* Yes No Did you collaborate with the nominee to put together this nomination?:* Yes No The College encourages nominators to collaborate with their nominees to put forth a strong, wellformed nomination. How did you first hear about the Grinnell College Young Innovator for Social Justice Prize?:* Please select the primary means by which you learned of the Grinnell Prize. The Grinnell Magazine At a Grinnell College-sponsored event Grinnell College website Poster/flyer Direct from a Grinnell College office (e.g., Office of the President, Office of Development & Alumni Relations) from a Grinnell alumnus/alumna from a Grinnell student from a Grinnell faculty or staff member from a Grinnell trustee from a person not affiliated with Grinnell College Word of mouth The Care 2 Network Chronicle of Higher Education Chronicle of Philanthropy Nonprofit News Atlantic Monthly The Economist The Nation The Des Moines Register Article online/in print Facebook LinkedIn Twitter Philanthropy News Digest (Foundation Center) The New York Times nytimes.com WANGO Blog Internet search Other (specify below) If other, please specify how you heard about the Prize: Did you submit a nomination for a past Prize?:*

4 Yes No Are you now nominating the same individual that you nominated for a past Prize?:* Yes No Not applicable Do you plan to submit or have you submitted another nomination for the 2014 Prize?:* Yes No Information Regarding the Nominee(s) Information regarding the individual(s) you are nominating: Single Nominee or First Nominee First and/or Additional Names:* Last Name:* Nominee s Title:* Address:* This is the primary means we will use to contact the nominee if chosen to continue with the selection process. Phone number:* Provide a phone number where we can contact the nominee if chosen to continue with the selection process. Birth Date:* Must be born on or after 1 January Sex:* Male Female Other Nationality/Citizenship:* Select the nominee s country of nationality/citizenship from the drop-down menu on the online nomination form. If the nominee has dual citizenship, please note the second country in which the nominee has citizenship: Select the nominee s country of dual citizenship from the drop-down menu on the online nomination form. Ethnicity/Race: Mexican, Mexican Am., Chicano Puerto Rican Cuban Other Hispanic or Latino origin* White Black, African Am., Negro African Middle Eastern

5 American Indian or Alaska Native* Asian Indian Chinese Filipino Japanese Korean Other Asian* Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander* Some other race* Vietnamese More than one ethnicity/race may be selected. For an ethnicity/race not listed above; or to specify another Hispanic or Latino origin, or Asian or Pacific Islander; or to identify a particular American Indian or Alaska Native tribe, enter the information below. *Other ethnicity/race/tribe: Grinnell Affiliation:* Grinnell Student (enter class year below) Grinnell Staff Grinnell Faculty Grinnell Alumni (enter class year below) Grinnell Trustee No Affiliation Grinnell Alumni/Student Class Year: What awards has the nominee received?:* Awards from high school and undergraduate institutions (apart from national fellowships) should not be included. This section is intended to highlight awards and honors the nominee has received as a result of the nominee s social justice-oriented work. Second Nominee (Joint Nomination Only!) If this is a joint nomination, all fields below are MANDATORY except ethnicity/race. First and/or Additional Names: Last Name: Nominee s Title:

6 Address: This is the primary means we will use to contact the nominee if chosen to continue with the selection process. Phone Number: Provide a phone number where we can contact the nominee if chosen to continue with the selection process. Birth Date: Must be born on or after 1 January Sex: Male Female Other Nationality/Citizenship: Select the nominee s country of nationality/citizenship from the drop-down menu on the online nomination form. If the nominee has dual citizenship, please note the second country in which the nominee has citizenship: Select the nominee s country of dual citizenship from the drop-down menu on the online nomination form. Ethnicity/Race: Mexican, Mexican Am., Chicano Puerto Rican Cuban Other Hispanic or Latino origin* White Black, African Am., Negro African Middle Eastern American Indian or Alaska Native* Asian Indian Filipino Japanese Korean Vietnamese Other Asian* Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander* Some other race* Chinese More than one ethnicity/race may be selected. For an ethnicity/race not listed above; or to specify another Hispanic or Latino origin, or Asian or Pacific Islander; or to identify a particular American Indian or Alaska Native tribe, enter the information below. *Other ethnicity/race/tribe:

7 Grinnell Affiliation: Grinnell Student (enter class year below) Grinnell Staff Grinnell Faculty Grinnell Alumni (enter class year below) Grinnell Trustee No Affiliation Grinnell Alumni/Student Class Year: What awards has the nominee received?: Awards from high school and undergraduate institutions (apart from national fellowships) should not be included. This section is intended to highlight awards and honors the nominee has received as a result of the nominee s social justice-oriented work. Information Regarding the Nominee(s) s Organization or Work For mandatory fields that are not applicable to the nominee(s), please write N/A (not applicable) in the space provided. What is the primary focus of the nominee s accomplishments?:* Agriculture, Food Animal Related Arts, Culture, and Media Business Civil and Human Rights Crime, Legal Services Education Environmental Sustainability, Protection, and Conservation Government Health Human Services International Development, Foreign Affairs, and National Security Philanthropy and Volunteerism Public Safety, Disaster Preparedness, and Relief Religion, Spiritual Development Research, Think Tank Social Entrepreneurship Youth Leadership, Development No Focus Area Other (describe below)

8 Select the focus area which best describes your nominee s accomplishments. For a description of the various focus areas or areas of accomplishments, please view Nominator/Nominee Focus Area Descriptions. If other focus area or area of accomplishment, please briefly describe: What is the secondary focus of the nominee s accomplishments, if any?: Agriculture, Food Animal Related Arts, Culture, and Media Business Civil and Human Rights Crime, Legal Services Education Environmental Sustainability, Protection, and Conservation Government Health Human Services International Development, Foreign Affairs, and National Security Philanthropy and Volunteerism Public Safety, Disaster Preparedness, and Relief Religion, Spiritual Development Research, Think Tank Social Entrepreneurship Youth Leadership, Development No Focus Area Other (describe below) Please briefly describe the nominee s work in 1-2 sentences:* Organization Name:* Organization Website:* Responsibility Within Organization:* For joint nominations, describe the responsibilities for both individuals. Profit Orientation of Organization:* Nonprofit For-profit Other Not Applicable If the nominee does not have an organization, please select Not Applicable. If other type of organization, please briefly describe: Where the Nominee Works All fields below are MANDATORY unless the information requested is not applicable to your nominee(s). If that is the case, please check the appropriate box.

9 Majority of Work Performed Where is the nominee s work mostly performed in? For example, a nominee might have their organization headquartered in Boulder, Colorado, U.S.A., with a satellite/administrative office in New York City, but most of the innovative work is performed in the country of Uganda. In this instance, the nominator should choose Uganda to answer this question. Country:* Please select the country where the majority of the nominee s work takes place from the drop-down list on the online nomination form. If the nominee s work is equally performed in other countries, please note these other countries here: Organization Headquarters If not applicable, check here: Not applicable to my nominee(s) Street Address: City/Town: Zip Code/Postal Code: Country: Select the country location of the organization s headquarters from the drop-down list on the online nomination form. Phone Number: Satellite/Field Locations Does the nominee s organization operate in locations other than at headquarters? If so, for each satellite or field office, enter the addresses for these offices below. If not applicable, check here: Not applicable to my nominee(s) Number each separate location and enter the complete address below: For example: (1) 123 Main Street, Hartford, Connecticut, 12345, U.S.A.; (2) Escuela Rural 45, X5187XAB San Clemente, ARGENTINA; (3) 1234 Church Street, Colloyn, PRETORIA, 0083 SOUTH AFRICA Other Locations Where else does your nominee work that is not listed above? If not applicable, check here: Not applicable to my nominee(s)

10 Provide city/town/locality, region, state/province, and/or country name: Nomination Essay The College recommends that you draft and review your essay offline (e.g., in a Word document), and then copy and paste the essay into the online form when you are ready to submit the nomination. Please note that rich text- such as bold, italics, or underlining- will not show up in the nomination. The essay is word limited; there is no need to include the information you have entered above in the essay. There is no requirement that the 750 words be distributed evenly between the three or four questions or that the questions be addressed in any particular order. The College leaves the structure of the essay to the discretion of the nominator to best tell the nominee s story. Nomination Essay: In 750 words or less, address the following: (1) Describe the nominee s innovative contribution to his or her field or community. Articulate how the nominee is innovative and distinguishable from others doing similar work. (2) Describe the impact the nominee s innovation has had in his or her field or community ( to serve the common good ). Articulate the quality and/or quantity of the impact. Provide concrete evidence, if possible. (3) Why is the nominee a force for social justice, and how has the nominee demonstrated the skills of critical thinking, creative problem-solving, and free inquiry? (4) If this is a joint nomination of two individuals, describe the collaborative relationship the two individuals bring to their field or community. For additional guidance in answering the questions above, please review the Frequently Asked Questions (FAQs). Nomination Essay (Maximum of 750 Words):* Release of Nomination I understand there is a 750-word limit for my nomination essay. I understand that the information in the essay must be self-contained; hyperlinks and references to other information found outside of the essay will not be considered in the initial review process.

11 I have proofread my nomination essay and understand that I will not be able to make changes to the essay after submitting my nomination. By submitting this form, I agree that my name and nomination will be released to the nominee if the nominee is chosen to continue with the selection process. My nomination essay is in English. I understand that essays submitted in another language will not be reviewed. I have read and understand the foregoing statements:* Yes

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