LAMM Nomination Form

Leadership Academy for Middle Managers

For more information, please contact Deborah Reed, LAMM Program Manager

LAMM Participant Nomination Form
Submission Deadlines for the final 3 programs are as follows
Regions 1 and 2:	April 23, 2012
Regions 3 and 4:	July 27, 2012
Regions 9 and 10	November 13, 2012

About the Nominee

Name*

Employer (Agency or Tribal Child Welfare Organization)*

Job Title*

Submit an organizational chart -OR- describe the nominee's primary job responsibilities, including the number and type of positions he/she oversees and consults:

Work Mailing Address*

Work Address Con't

Work Address City*

Work Address State*

Work Address Zip Code*

Work Phone*

Cell Phone

Email*

I acknowledge the above is accurate*

Optional Information that will expedite travel planning

Home Mailing Address

Address Con't

Home Address City

Home Address State

Home Address Zip Code

Date of Birth

Name as it appears on ID

The LAMM is recruiting individuals who are leaders of programs in states, tribes and agencies and who are responsible for one or more specific change initiative that is supported by the leadership of the state child welfare agency or tribe. Please answer the questions below describing in detail the change initiative that will be the focus of the nominee’s work.
1. The name of the change initiative:
2. Is the initiative part of the agency’s Implementation Center project, Program Improvement Plan, or other state/agency–sponsored project?
3. What is the desired outcome?
4. Describe what has been done to–date:
5. What needs to be done to move the change initiative forward?
6. What is the nominee’s span of responsibility and role in relation to this change initiative?
Please note: The change initiative submitted will be shared with a variety of people involved in the selection and coaching process, as well as with other LAMM participants.

Essay

About the Nominee's Supervisor/Administrator

Name

Employer/Organization

Job Title

Phone Number

Email Address

Relationship to Nominee

By submitting this nomination, I wholeheartedly recommend this nominee for participation in the LAMM. I agree to support this person’s participation in the pre-work, the five-day residential training, subsequent peer networking activities, and the opportunity to practice what he/she learns. I am aware that travel (possibly out of state) is required (expense covered by training program) and I approve that travel. I also agree to take a series of short, web-based questionnaires as part of the LAMM evaluation.

Check to agree to the above statement.*