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Mail or fax the completed form to the address listed below.
This form is located at http://www.michiganspeechhearing.org/ptyform.html

Public School Program of the Year
Nomination Form
Michigan Speech-Language-Hearing Association requests Exemplary Program nominations.

The Michigan Speech-Language-Hearing Association's Public School Committee requests nominations for Speech-Language and/or Hearing Programs to be recognized.  A program may be nominated by anyone who feels it is deserving of statewide recognition.  Please complete this form and return it to the MSHA office.  The Public School Committee will review all nominations and select several programs for possible on-site review.  See Guidelines page for more information.  PLEASE TYPE OR PRINT LEGIBLY.  Thank you!

Program Name:                                                                                                                                                                     

School District:                                                                                                                                                                        

Address:                                                                                                                                                                                    

                                                                                                                 Phone:(            )                                                          

Fax:(          )                                                   E-Mail:                                                                                                                    

Primary person(s) providing services for this program and their title/position:                                                                           

Any other person(s) to be included in this nomination:                                                                                                               

Brief description<disability area, ages of students, etc.:                                                                                                           

                                                                                                                                                                                                    

Please list 5 qualities which you feel make this program exceptional (attach an additional sheet if necessary):

                                                                                                                                                                                                   

                                                                                                                                                                                                   

                                                                                                                                                                                                    

Nominated By:                                                                                                                                                                         

Address:                                                                                                                                                                                    

Phone Work:(           )                                                                     Home:(           )                                                                     

Fax:(          )                                                   E-Mail:                                                                                                                    

Superintendent responsible for this program:                                                                                                                 

Address:                                                                                                                                                                                    

Phone Work:(           )                                                                     Home:(           )                                                                     

Fax:(          )                                                   E-Mail:                                                                                                                  

Return to:   MICHIGAN SPEECH-LANGUAGE-HEARING ASSOCIATION
790 W. LAKE LANSING RD. STE. 500-A   EAST LANSING, MICHIGAN 48823
(517) 332-5691  FAX: (517) 332-5870
DEADLINE FOR NOMINATIONS December 17, 2007