Alpha Theta State
Ona Patterson Award Application

Applicant Data: 
         Last                  First
   Name:                 

         Street                     City             State  Zip
Address:       

  Phone:  -
       
Alpha Theta State Chapter:  
       Alpha
       Beta
       Gamma
       Zeta
       Theta
       Iota
       Kappa
       Lambda
       Mu
       Nu
       Xi
       Omicron
       Pi
       Rho
       Sigma
       Chi
       Psi
       Omega
       Alpha Alpha
       Alpha Beta
       Alpha Gamma
 

Years of Delta Kappa Gamma membership:  

Current member of Delta Kappa Gamma  Yes  No 

Evidence that the applicant inspires children's literacy through writing: 

      
      
      
      
       

Evidence that the applicant participates in professional writing experiences:

      
      
      
      
       
     
Evidence that the applicant serves as a role model to students as a writer:

      
      
      
      
       

Evidence that the applicant integrates the use of technology in expressive/creative writing:

      
      
      
      
       

Personal Statement regarding children as writers:
      
      
      
      
      

References

         Last                First
   Name:  
         Street                     City             State  Zip
Address:       

  Phone:  -

         Last                First
   Name:  
         Street                     City             State  Zip
Address:       

  Phone:  -

Instructions for Submission
Fill in form, print it out on your computer, and send via US Mail to:

Nyla Adamson 
1901 Vintage Woods Court
Salt Lake City, UT 84117

Submission deadline: March 15, 2005