4th Annual Spirit of Caring Award Nomination Form
Name *
I have informed this person about the nomination. Please check response.
(Only persons who have been informed of their nomination will be considered for the Spirit of Caring Awards. *
 YES 
 NO 
Email
Phone Number

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Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Please check the box that best describe the receiver of care: *
 A disabled child or adult - newborn to 59 years of age 
 A chronically ill child or adult - infant to 59 years of age 
 An adult 60 years of age or older who is chronically ill 
 A person with Alzheimer's Disease or another dimentia 
Check one or more
Receiver of care is a resident of: *
 Own home or family member's home 
 Skilled nursing facility or personal care home 
Check one or more
Receiver of care:
 is currently living 
 is deceased within the year 
Check one or more.

Please check the box that best describe the unpaid giver of care:

A description of the section goes here.
This person has provided care and/or assistance for:
Caregiver is currently
Caregiver cares for:
Caregiver cares for: *
 Grandparent(s) 
 Parent(s) 
 Child(ren) 
 Other 
Check one or more
Reasons Why You Are Nominating This Caregiver? *
Please Read This Before Submitting *
 I am aware that if my Spirit of Caring Nomination form is chosen, I will sign a permission form and the caregiver's story may be read on the radio in November on WDAD Todd Marino's Indiana in the Morning Show 
Name of person making the nomination *
Phone Number

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Date

MM		/
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YYYY
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