CHARACTER COUNTS!_SM Recognition Program
                                                    Nomination Form
                                                    www.character60108.org

The program is easy!  All you have to do is complete this form when you see a member of the Bloomingdale Community
who lives, works, or attends school in Bloomingdale exhibiting outstanding character. Just check the pillar that applies
and write a brief description of what you saw the individual doing. Return this form to School District 13, Westfield
Middle School, Erickson School, DuJardin School, Winnebago School, Bloomingdale Police Department, Village Hall,
Bloomingdale Park Distrrict - the Johnston Recreation Center, Bloomingdale Township, or the Bloomingdale Library.
Public recognition will be awarded at the CHARACTER COUNTS! Annual Recognition Breakfast in on Saturday, 9 May.
Forms must be submitted by April 22.

______Trustworthiness                    Individual is honest. Keeps promises. Shows commitment and courage. 
______Respect                               Follows the Golden Rule. Is tolerant of people’s differences. Respects others’ 
                                                                     opinions.  Settles disputes peacefully.
______Responsibility                       Individual is accountable for choices. Sets a good example. Uses self control.
                                                                     Always does his/her best.
______Fairness                               Always willing to listen. Teaches and models fair play.
______Caring                                  Act of kindness. Individual is compassionate. Expresses gratitude.
                                                                     Helps others.
______Citizenship                           Obeys laws and rules. Protects the environment. Respects authority. Is a good 
                                                                     neighbor.  Cooperative.

Name of person being nominated:__________________________________________________________________

Address and phone number of person being nominated: _______________________________________________

Name of person submitting form:___________________________________________________________________

Address and phone number of person submitting form:_________________________________________________

Description of nominee’s display of character (Attach an additional sheet if necessary.)_________________ 
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

For additional information, please call Sandy at 630 529-3650 or email [email protected] or fax to 630 529-9184

                    The CHARACTER COUNTS!_SM Recognition Program is a project of the
                                    Bloomingdale CHARACTER COUNTS! _SM Coalition.