EmailMe Form - Hearts of Golds Awards Nomination Form 2024

Please complete the following for the individual you wish to nominate for a Hearts of Gold Award:

Which Award Are You Nominating For?

Excellence In Caregiving Award: Individuals who go above and beyond the call of duty in providing care for individuals with special needs

Wall of Fame Award: Community innovators who have clearly excelled in helping the special needs community at large.

*Select all that apply. You may select one, both, or neither.

Nominee's Name *

First Last

What organization (if any) is the nominee affiliated with? *

N/A if inapplicable

Nominee's Phone Number *

### - ### - ####

Nominee's Email *

Nominee's Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Your Name *

First Last

Your Phone Number *

### - ### - ####

Your Email *

In 150 words or less, please answer the following questions:

What specifically has this individual done for the special needs community to merit recognition? *

How have the actions of this individual impacted you/your family personally? *

Tell us three extraordinary efforts/accomplishments to help individual(s) with special needs. *

What legacy will this nominee leave due to their efforts? What is their lasting impact? *

In 250 words or less, please answer the following question:

Why do you believe this person should be celebrated? *

Please Note:

Please review your nomination before submitting to ensure nominee contact information is correct. Incorrect information could disqualify your nomination and prevent it from being considered for an award.

We reserve the right to place your nominee into the category they best fit into regardless of the award selection.