Instructions for Application

1. Complete application below no later than September 30.

2. Please obtain consent of nominee prior to submitting application.

3. Send any supporting documents if available (news article, educational program or brochure, video clip, or web link) to Colleen Harper at

4. The ASPEN Public Policy Committee will review the nominations, hold a conference call, and decide on the awardee by Nov. 15th. The nominees will be notified shortly thereafter.

* 1. Nominator's Name

* 2. Nominee's Name and Contact Information

* 3. Is this nominee a (check one)

* 4. Has the nominee given consent to you to be nominated?

* 5. Have they given permission "to print their story" in ASPEN publications or on the website?

In no more than 500 words, please provide the following information about the nominee and the advocacy activities that this nominee has participated in on behalf of others receiving PN or EN.

* 6. A brief paragraph describing information on the nominee (such as how long on EN/PN if a consumer and who they take care of if they are a family member or caregiver).

* 7. Advocacy Activities that this nominee participated in:

* 8. Impact these activities had on others (for example, how many people did you reach? Who has used what you have developed?):

* 9. What was the outcome or potential outcomes of these advocacy efforts? (For example, was legislation passed, funding obtained, support group established, book published?)