Registration Page The Diller Teen Tikkun Olam Awards recognize Jewish teens in the United States who have demonstrated remarkable leadership and impact through projects that embody the values of tikkun olam, “repairing the world." Directions: Directions: All application questions should be completed by the teen applicants. All required fields on a single page must be completed before that page can be saved. Note: It is recommended that the applicant draft and save long form answers prior to submitting online. You can draft your answers in this downloadable form (ADD LINK). If you have any questions, please contact us at: [email protected]
415-684-8618 via text: text diller to 31996 Personal Information: First Name:
Last Name:
Email:
Cell Phone:
State:
Eligibility:
To be eligible for the award, the following statements must all be True.
I will be 13-19 years old on January 7, 2022: Yes or No
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I am a United States resident: Yes or No I have not been paid for work on my project: Yes or No If not "True" or you are unsure, please contact the Tikkun Olam Awards Team before proceeding to confirm eligibility. I self-identify as Jewish: Yes or No I do not have a sibling who has received a Diller Teen Tikkun Olam Award in the past five years (2017-2021): Yes or No I am in a current leadership role for the project for which I am applying: Yes or No I have read and agree to uphold the values of the Helen Diller Foundation as described here. https://www.dillerteenawards.org/values/ Yes or No Personal Information / Contact First Name:
Last Name: Email:
Birthdate:
Mailing Street:
Mailing City:
Mailing State:
Mailing Zip/Postal Code:
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Personal Information / Affiliations Current Academic Level Middle School/Junior High School High School College/University Not in school
School Name:
School Address:
Synagogue Name, if applicable:
Synagogue Address:
Select all programs, clubs, groups, and organizations where you have involvement. • Add New Organization • International Baccalaureate Program • Alliance for Youth Action • International Thespian Society • Ambassador Leadership Summits • Model United Nations • American Computer Science League • Mu Alpha Theta: Math Honor Society • American Jewish Coalition • National Art Honor Society • Amnesty International • National Honor Society • B'nei Akiva • National Robotics League • BBYO • National Speech and Debate Association • Best Buddies International • National Student Leadership Foundation • Boy Scouts of America • NCSY • Chabad on Campus • NFTY • CTeen • Repair the World • Diller Teen Fellows • Robotics • FIRST Robotics • Science National Honors Society • Friendship Circle • Science Olympiad • Future Business Leaders of America • Student Government • Habitat for Humanity • Technology Student Association • Hazon JYCM • USY • Hillel International • Young Judea • Honeycomb (previously named Jewish • Youth Volunteer Corps Teen Funders Network)
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Personal information Describe your involvement with programs, activities, or volunteering, outside of this project:
Share how you connect to Jewish identity and/or heritage. There is no intention to elicit a particular answer; Jewish connection takes many forms:
What does tikkun olam mean to you?
Share your personal story:
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Project Information Please reference the glossary at the bottom of this page in order to understand how the Tikkun Olam Awards defines specific terms. Words with definitions are marked with an asterisk. All responses should be under 200 words.
Select up to three project issue areas. Animal Rights Gender Equality Antisemitism Health Arts Housing Security Civic Engagement Immigration Climate Justice LGBTQ Community Building Mental Health COVID response Philanthropy Disability Justice Political Advocacy Diversity, Equity, Inclusion Racial Justice Economic/Wealth Distribution Refugees Education Senior Support Elder Support Voting Environment Youth Leadership Food Security When did the project begin? (Month)
When did the project begin? (Year)
Share how your project began, including who and what inspired you.
Share your project's mission statement*. Include the target population* you serve/reach, what social issue(s) your project addresses, and what methods* you use to achieve your mission.
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Share the goals of your project and a detailed outline of what your project does.
Share a video link (e.g., youtube, google, vimeo of up to 2 minutes) describing what your project does. Include your name, the name of your project, and when it started.
Glossary Mission Statement: A formal summary of the aims and values of a project. Target Population: Group of individuals that the project intends to benefit. Methods: The form(s) of action for accomplishing something.
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Leadership Which of these best describes your contribution to the project? Founded the project or expanded or added to the existing project. If founded the project: Select which title describes your role as it relates to the founding of this project? Solo Founder Co-Founder Founding member If Co-Founder: Teens who have created and co-led with others are welcome to apply individually for the Tikkun Olam Award. In such cases, each applicant will be considered and evaluated separately for their leadership role and impact, and no more than one applicant can be selected as an award recipient.
What is the co-founder's title and specific responsibilities?
What are your individual contributions to the project?
If founding member: Explain your role in the founding of the project, and your individual contributions to the project’s growth.
If expanded the project: How long have you been involved in the project?
Describe your history with the project, including how you first became involved and the process of expanding the project.
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List your individual contributions and accomplishments towards the expansion of the project.
How much time on average do you spend on your project per week during the academic year? (if currently in school)
How much time on average do you spend on academics including homework and studying per week? (if currently in school)
How much time on average do you spend on non-academics, not including your project, per week? ((i.e. sports, volunteering, family commitments, jobs, etc.)
Describe how you balance these commitments.
Describe in detail your ongoing leadership responsibilities within the project.
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Define and describe your leadership style and approach. Include how you have responded to challenges and how you have grown as a leader within the project.
Glossary Solo Founder: The sole person who started a project. Co-Founder: One of two or more people who started a project. Founding Member: A person who has been a leader in a project since its founding.
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Impact Please reference the glossary at the bottom of this page in order to understand how the Tikkun Olam Awards defines specific terms. Words with definitions are marked with an asterisk. All responses should be under 200 words. What is the primary difference your project seeks to make?
How do you assess how effective your project is at making this difference?
List and describe the qualitative* impacts of your project.
List and describe the quantitative* impacts of your project.
Does your project rely on the recruitment of others as volunteers? Yes or no If Yes: How many volunteers have been recruited?
How do you recruit and retain volunteers?
On average, how many hours per week does each volunteer contribute?
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Describe how you involve members of your project's target population in influencing decision-making.
Glossary Impact: The tangible effect a project has on someone or something. Qualitative Impact: Assessment of how the project has reached its goals using narrative descriptions of change. Quantitative Impact: Assessment of how the project has reached its goals using numbers.
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Organizational Structure: Please reference the glossary at the bottom of this page in order to understand how the Tikkun Olam Awards defines specific terms. Words with definitions are marked with an asterisk.
All responses should be under 200 words.
Did your project/leadership grow from an already existing project?
If so, what was the existing project name?
Is your project dedicated to raising funds/volunteers/resources/awareness for an existing organization?
If so, what is that organization's name?
Describe the organizational structure* of your project. List the names and titles of each person involved and describe the role of volunteers, organizational partners*, and parent organizations*.
Describe how you receive support from adults
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What do you envision for your project going forward? Include any plans you have to transition leadership in the future. If you do not have such plans, explain why they are not necessary.
Glossary Organizational Structure: How activities such as task allocation, fundraising, and supervision are directed toward the goals of the project. Organizational Partner: A person, institution, or groups which works directly with the project in order to support reaching the project mission. Parent Organization: An organization that supervises, coordinates, and regulates funding of a project.
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Financial Information Please reference the glossary at the bottom of this page in order to understand how the Tikkun Olam Awards defines specific terms. Words with definitions are marked with an asterisk. All responses should be under 200 words. Is your project a registered 501(c)(3) *? Yes No In Progress Fiscal Sponsorship* with Umbrella organization
If yes, what is your organization’s Employer Identification Number?
Do you raise funds that help run this project? Yes No
If yes, what amount have you raised to date? USD:
Describe how the funds are allocated.
Do you raise funds to donate to a cause? Yes No If yes, list each donation you have made as an organization. Include the amount donated, date donated, and organization/cause donated to:
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Has anyone involved in your project been compensated? Yes No If yes, what was the amount of compensation*, to whom and what?
Have you received donations of goods and services? Yes No Describe the donations of goods and services you have received.
Attach budget if applicable: 4MB, PDF format only
Glossary 501 (c)(3): Government status of a non-profit which allows the organization to be exempt from federal income tax. Fiscal Sponsorship: A partnership between your project and a 501 c-3 non-profit organization in which your project receives access to grants and tax-deductible contributions, through the 501 c- 3 organization. Compensation: The money received by someone for their work on a project.
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Marketing and Outreach Please reference the glossary at the bottom of this page in order to understand how the Tikkun Olam Awards defines specific terms. Words with definitions are marked with an asterisk. All responses should be under 200 words. Describe the method(s)* you use to market your project (traditional and digital).
Submit up to four links to media/press highlighting your project, with publish/air date and network/press company
Include the web addresses and handles to your organization's web and social media presence. Leave blank if not applicable.
Website Twitter TikTok Instagram Facebook Other Social Media
List metrics* measuring engagement and explain why each metric is relevant to increasing, sustaining, and amplifying your project's mission. (e.g.,,email list subscribers, website visitors, social media followers and impressions, phone calls received, fliers handed out).
Glossary Metrics: Measures of quantitative assessment.
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Supplemental Information: All responses should be under 200 words.
Share any additional information you would like the selection committee to know about you and your project leadership.
List any awards, grants, or public recognition your project has received, or you have received on behalf of your project.
You may include up to four attachments of supplemental materials, not exceeding a total of ten pages. You may only include attachments which fall under the dropdown list of acceptable supplemental materials. Please name all files with your full name and the file type. i.e., "FullName-Resume". Type of supplemental material: Curriculum Professional Correspondence Photographs Awards or Certificates Resume Professional Writing Marketing Material Budgets
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References All applicants must provide the names and contact information of three people who are familiar with your leadership and your project. References may not be someone related to you. Your three references should include: Reference 1 - Adult mentor or advisor familiar with your project Reference 2 - Collaborator or colleague (can be adult or youth) Reference 3 - Any other reference not related to you Please only list individuals after you have their permission to list them as a reference. We MAY contact all or none, to provide a confidential reference. Note: In some cases, staff may contact you or others familiar with your project for additional information.
Reference 1:
First Name:
Last Name:
Email:
Phone:
Relationship:
Reference 2:
First Name:
Last Name:
Email:
Phone:
Relationship:
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Reference 3:
First Name:
Last Name:
Email:
Phone:
Relationship:
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Miscellaneous Information – Your answers in this section will not be forwarded to the committee.
Have you applied to the Awards before? Yes or No
CONDITIONAL (Yes) - Which years have you applied? 2021, 2020, 2019, 2018, 2017, 2016, 2015
Where did you hear about the Diller Tikkun Olam Awards? (Select all that apply): Please specify (Ex: Name of website, Name of person): Colleague or Friend Diller Email List Family Member Local Jewish Organization Nominator Online Advertisement Other Past Nominee or Applicant Past Recipient Print Advertisement Scholarship Website Social Media Web Search
Please specify (e.g, name of website, name of person):
Demographics Information (Optional) To address issues of diversity and representation, we are asking the following demographics questions for survey purposes only. This information will not be attached to your application and will be randomized for data collection only.
Do you identify as: Woman/Girl (cis gender) Man/Boy (cisgender) Trans, Transgender woman/girl Trans, Transgender man/boy Nonbinary Genderqueer I prefer to self-describe I prefer not to answer
Self-describe as:
Do you identify as transgender/trans? Yes or No
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Do you identify as: African American Middle Eastern Asian/Asian American Native American/Alaska Native Black/African Pacific Islander/Native Hawaiian Caucasian/White Mixed Race Latinx/Latino/Latina/Hispanic I prefer to self-describe
Do you identify as a Person of Color? Yes or No
If you identify as ethnically Jewish, which of the following most closely reflects your identity?
Ashkenazi Mizrahi Sephardi Some combination Ashkenzai, Mizrahi, and/or Sephardi Other: (Please specify): I do not identify as ethnically Jewish
Do you identify as disabled? Yes or No
Do you identify as LGBTQ+? Yes or No
Confirmations
By checking this box, I agree to receive communications via text about my application.
By checking this box, I confirm that I completed this application myself and all of the information is accurate to the best of my ability.
By checking the boxes below, if selected as a recipient, I accept the following requirements:
I will attend the awards events in San Francisco, scheduled for August 2022.
I will be available during June and July to participate in the video recording or submit footage for the Diller Tikkun Olam Awards recipient video.
I will periodically provide brief updates and contact information (email, cell, address, etc.) to the Helen Diller Family Foundation after receiving the award.
I will use the award money either to further my Tikkun Olam work or for my education.
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