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2012 Impact Award Nomination Form

Award Category: *

Emerging Leader

Community Champion

Lead with Experience

Inspirational Achievement

Environmental Impact Award

Section 1: Volunteer Info

Name of Nominee: *

If group, total number of volunteers:

Address: *

City, State: *

Zip: *

Daytime Phone: *

Email: *

Age Group: *

17 or under

18-22

23-45

46-54

55-64

65 or older

Employer (optional):

Section 2: Nominator Info

Name of Nominator: *

Title:

Relationship to Nominee: *

Daytime Phone: *

Cell Phone:

Nominating organization, school, or business (if applicable):

Geographic Service Area (if applicable):

Section 3: Volunteer Service

Organization Served: *

Impact Area: *

Youth/Education

Poverty

Environment/Animals

Seniors

Military/Veterans

Other

If Other, please explain:

Years nominee has volunteered (if known):

Hours volunteered in 2011 (if known):

Provide two examples of how the nominee helped to overcome a challenge, increase an organization's capacity or meet a local need:

Describe how this nominee's actions or leadership inspires others to make a difference:

Section 4: Additional Info

Any additional information or comments:

Upload a photo of the nominee (optional):

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