To:

    All Steuben County

    Organizations - Churches - Schools - Agencies

    Government Officials - Community Members

    From:

    The Jack Lisi Youth Award Board of Directors

    Re:

    Annual

    “JACK LISI YOUTH AWARD”

    RECOGNITION-INCENTIVE FOR YOUNG ADULTS

    TO ACCESS FORM ONLINE: http://www.steubencony.org/countyforms.html

    The Jack Lisi Youth Award Board of Directors and Steuben County Youth Bureau

    are pleased to announce that we will be presenting the Annual “Jack Lisi Youth

    Award,” Recognition - Incentive for Young Adults. This award will be given to

    young people age 16 through 21, living in Steuben County.

    According to Angie Lisi, (Jack’s wife) “Jack had compassion, concern and

    respect for youth who had problems which hindered their ability to achieve and he felt that often they were not given enough credit. Jack believed that what was

    needed was someone to care, show support, assistance and guidance in order for

    youngsters to become contributing members of society.”

    This award program targets this often overlooked population and offers

    incentives to youth who have shown interest and ambition toward academic or

    career/employment goals.

    A maximum of eight winners from within Steuben County will be selected

    by a committee to receive awards and incentives, dependent upon

    information expressed on the attached recommendation form.

    The awards and incentives are listed:

    ? Grant toward continuing education

    ? Financial Assistance to colleges

    ? Financial Assistance for other post secondary education

    ? Certificate for Books and/or educational material

    ? Certificate for “work related materials”

    Awards will be presented at a County-wide banquet on first Friday in May.

    The value of the award has been increased significantly.

If you know of an individual deserving this type of recognition, please complete

    the attached recommendation form and return to:

    Steuben County Youth Bureau

    Jack Lisi Youth Award Board of Directors

    3 East Pulteney Square

    Bath, N.Y. 14810

     stThe deadline for recommendations is March 21. If you have any questions or are in need of additional

    applications, please contact the Jack Lisi Youth Award Board of Directors at the above address or phone

    1-800-346-2211. Thank You!

     (Page 1 of 4)

    Annual

    “JACK LISI YOUTH AWARD”

    RECOGNITION-INCENTIVE FOR YOUNG ADULTS

    Recommendation Form

    stDue no later than March 21

    NOTE: Please type or print legibly. Fill in completely!

    All information is treated as confidential.

    Nominee’s Name: ( )

    Last First Middle Initial Male/Female

    Address:

    Number and Street

    City State Zip Code

    Phone: Date of Birth:

    School: Year/Grade:

    (If Applicable)

    Soc. Sec. #

Recommended By: Name:

     Address:

     Phone:

Parent(s)/Guardian(s) Name:

     Address:

     Phone:

    Please complete the following to the best of your knowledge. Note: The Jack Lisi Youth Award is for 16 through 21 year old Steuben County residents who are often overlooked,

    struggling to be successful and need assistance to achieve. Use examples -- be specific --

    your words make the difference! Multiple nominations may help!

    If you need assistance, please call 607-664-2119.

    1) What are the Nominee’s future plans? Continue education? Enter the working world?

    Please, be specific:

    2) If continuing education, what field of study/interest?

    ?????

    ?Check if additional pages are attached (Page 2 of 4)

    Recommendation Form - “JACK LISI YOUTH AWARD” * Must be legible.

Nominee’s Name:____________________________________________

3) If entering the working world, what type of employment or occupation? Full or part-time?

4) Any special financial concerns? If so, what

5) Has the Nominee been recognized in the past with any awards or other distinctions? If so,

    what?

6) Extracurricular activities undertaken by Nominee including school, community, or other:

7) Any family personal or other circumstances that affected achievement of the nominee in

    school, work, or community activities?

8) Why do you feel this 16 through 21 year old is deserving of this most special

    recognition/incentive? Have they overcome barriers and are they sincerely trying to be successful?

    What makes them unique among their peers? Be specific. Provide examples where possible.

    ?

    ?Check if additional pages are attached

    (Page 3 of 4)

Recommendation Form - “JACK LISI YOUTH AWARD” * Must be legible.

Nominee’s Name:____________________________________________

    If the Nominee had their Choice of the Following, which award(s) do you think would be the most appropriate? Rank in order of preference by number with #1 given the highest priority and #6 given the lowest.

     Grant toward additional education

    Please explain:

     Financial Assistance to colleges

     Financial Assistance for other post secondary education

    Please explain:

     Gift Certificate for College Books and/or educational material

     Certificate for “work related materials”

Provide Two References, other than family, who could be contacted regarding this

    nomination:

     Name:

     Address:

     Phone:

     Relationship:

     Name:

     Address:

     Phone:

     Relationship:

    Please Return the Completed Form to:

    Steuben County Youth Bureau

    JACK LISI YOUTH AWARD, INC.

    Board of Directors

    3 E. Pulteney Square

    Bath, N.Y. 14810

    You may fax to: (607) 664-2189

    st Due No Later Than March 21

    TO ACCESS FORM ONLINE: http://www.steubencony.org/countyforms.html

     (Page 4 of 4)