2011 Diller Teen Tikkun Olam Awards – Application Form | Jewish Community Federation and Endowment Fund

2011 Diller Teen Tikkun Olam Awards – Application Form

Application Instructions:

The Diller Teen Tikkun Olam Awards recognize Jewish teen volunteers. Teens remunerated for their services are not eligible.

WARNING: Application forms cannot be saved mid-way. Please prepare and save a copy of your answers in a separate document, and then enter your answers into the form.

Put “N/A” for any question not applicable.

Supplemental materials (DVD’s, websites, articles, radio/television pieces, photo galleries) are encouraged; please post supplemental materials at online sites such as FLICKR, SmugMug, or YouTube. A section for listing the online links has been provided below.

Submission Deadline: January 21, 2011

Questions/Information: RobynC@sfjcf.org or 415.512.6432

TIP: Login or register on this site before submitting to view a copy of your complete submission later. You will not be able to save mid-way, but you will be able to return to this form to view your complete submission. Registration on this site is not required to submit this form or apply for the Diller Teen Tikkun Olam Awards, though it is recommended so that you can view your completed submission if you like.

Applicant Information

First Name: *

Last Name: *

Age and Date of Birth: *

Street Address: *

City, State and Zip: *

Home Phone: *

Cell Phone: *

Email: *

Names of Parents/Guardians: *

Parent/Guardian Phone Numbers: *

Where did you hear about the Diller Teen Tikkun Olam Awards? (Please be specific): *

Name of School: *

School's Street Address: *

School's City, State and Zip: *

Name of your Nominator (your name if you nominated yourself): *

**Your Tikkun Olam Involvement**

Title / Description of your Project: *

Who / What inspired you to take action? At what age did you begin your project?: *

Describe the goals of your project: *

In what specific ways do you see your project reflecting and embodying Jewish values?: *

If the project is based in the local community, is there growth potential for the project to reach the global community? Describe the results of the project: *

(If the goal of your project is to achieve local results, you will not be penalized for lack of global potential.)

What challenges have you discovered working on the project?: *

What excited you most about the project?: *

Did you need funds to carry out the project? If so, how did you obtain them? Did you have a business plan?: *

(If you have a business plan please post online and include link here.)

Do you have goals for the future of your project, or for your continued involvement in community service/tikkun olam?: *

(If you have trained peers to continue your project, please note that as well.)

In what ways has your project grown? Is there a plan for expansion? Please describe: *

Have you ever been compensated for your work with this project? If so, in what capacity?: *

Is there an organization involved with your project?: *

Name of Organization: *

Street Address: *

City, State and Zip: *

Website: *

Contact Person’s Name: *

Contact Person’s Title: *

Contact Person’s Phone: *

Contact Person's Email: *

Do you work with a Board of Directors? In what capacity? Describe your experience working with members of the Board: *

Supplemental Materials

List online sites and links here: *

Your Jewish Education and Affiliation

Your Religious Affiliation: *

Synagogue Name & Address: *

Jewish Day School Name & Address: *

Jewish Camp or Youth Group Name & Address: *

Are there aspects of Jewish life that you particularly connect with?: *

Have you ever visited Israel? If so, please describe your experience: *

(Who did you travel with? How old were you? What do you remember most?)

If applicable, describe how your leadership has impacted the local or global Jewish community: *

If applicable, describe how your community service has impacted the local or global Jewish community: *

Do you consider yourself a role model? In what specific ways?: *

Your References

Please provide contact information for TWO people (other than family members or your nominator) who will submit reference letters for you. They should be knowledgeable about your project and your involvement in the community. Please ask them to complete and submit the online Letter of Reference.

NOTE: If you nominated yourself then THREE reference letters must be submitted.

1. Reference Name: *

Title: *

Organization: *

Phone: *

Email: *

What is your relationship to this person?: *

2. Reference Name: *

Title: *

Organization: *

Phone: *

Email: *

What is your relationship to this person?: *

3. Reference Name (for self-nominated teens only):

Title:

Organization:

Phone:

Email:

What is your relationship to this person?:

I understand that, if selected as a recipient:

1. I will be available during June/July to be videotaped for the Diller Teen Tikkun Olam Awards DVD.

2. I will attend the awards events in San Francisco, Sunday, August 21 and Monday, August 22, 2011.

Your initials: *

Today's Date: *

Jewish Community Federation of San Francisco, the Peninsula, Marin and Sonoma Counties