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San Andreas Regional Centers
24th Annual Service Above Self Awards Dinner

Nomination Deadline - Wednesday, September 14th

Self Nominations will not be accepted:

Please share additional information about the Nominee in the Question Box:

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Question Title

* 1. PERSON MAKING THE NOMINATION

Name

Address

City/Town

Email Address

Phone Number

Question Title

* 2. CONSUMER ADVOCATE OF THE YEAR CONTACT INFO: (Please answer Question #3)

Name

Address

City/Town

Email Address

Phone Number

Question Title

* 3. QUESTION: How has the Consumer Advocate (an individual with a developmental disability) you are nominating go Above and Beyond in advocating for others? Please include additional information the Nomination Committee should know about the Consumer Advocate you are nominating.

Question Title

* 4. CONSUMER EMPLOYEE OF THE YEAR CONTACT INFO: (Please answer Question #5)

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 5. QUESTION: How does the Consumer Employee (an individual with a Developmental Disability) you are nominating go Above and Beyond their expected job duties with their current employer? Please include additional information the Nomination Committee should know about the Consumer Employee you are nominating.

Please provide a name and phone number of the employer and supervisor overseeing the individuals being nominated.

Question Title

* 6. SPECIAL EDUCATION TEACHER OF THE YEAR CONTACT INFO: (Please answer Question #7)

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 7. QUESTION: What contributions has the Special Education Teacher you are nominating make to advocate for their students and describe how they went Above and Beyond during the pandemic to help them achieve academic milestones? Please include additional information the Nomination Committee should know about the Special Education Teacher you are nominating.

Please provide the school phone number of the teacher being nominated.

Question Title

* 8. SUPPORTING LIVING STAFF OF THE YEAR CONTACT INFO: (Please answer Question #9)

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 9. QUESTION: Who does the Supported Living Staff you are nominating work for and what special accommodations did they do during the pandemic to support the lives of the consumers they serve and describe how they went Above and Beyond during these trying times? Please include additional information the Nomination Committee should know about the SLS person you are nominating.

Please provide the SLS supervisors name and phone number.

Question Title

* 10. RESIDENTIAL STAFF OF THE YEAR CONTACT INFO: (Please answer Question #11)

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 11. QUESTION: Who does the Residential Staff you are nominating work for and what special accommodations did they do during the pandemic to support the lives of the consumers they serve and describe how they went Above and Beyond during these trying times? Please include additional information the Nomination Committee should know about the Residential Staff you are nominating.

Please provide the Residential Staff's supervisors name and phone number.

Question Title

* 12. INDEPENDENT LIVING STAFF OF THE YEAR CONTACT INFORMATION: (Please answer Question 13)

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 13. QUESTION: Who does the Independent Living Staff you are nominating work for and what special accommodations did they do during the pandemic to support the lives of the consumers they serve and describe how they went Above and Beyond during these trying times? Please provide additional information the Nomination Committee should know about the ILS person you are nominating.

Please provide the ILS supervisors name and phone number.

Question Title

* 14. DIRECT CARE / SUPPORT STAFF OF THE YEAR CONTACT INFO: (Please answer Question #15)

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 15. QUESTION: Who does the Direct Care / Support Staff you are nominating work for and what special accommodations did they do during the pandemic to support the lives of the consumers they serve and describe how they went Above and Beyond during these trying times? Please provide additional information the Nomination Committee should know about the Direct Care Staff you are nominating.

Question Title

* 16. VOLUNTEER OF THE YEAR CONTACT INFO: (Please answer Question #17)

Name

Address

City/Town

Email Address

Phone Number

Question Title

* 17. QUESTION: What contributions did the Volunteer you are nominating make during the pandemic to support the lives of individuals with developmental disabilities and how did they go Above and Beyond during those trying times? Please provide additional information the Nomination Committee should know about the Volunteer you are nominating.

Please provide a contact name and number for the organization they volunteer for.

Question Title

* 18. EMPLOYER OF THE YEAR CONTACT INFO: (Please answer Question #19)

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 19. An employer who hires individuals with disabilities.

QUESTION: What accommodations did the Employer you are nominating make during the pandemic to support employees and how did they go Above and Beyond to keep individuals with developmental disabilities employed? Please provide additional information the Nomination Committee should know about the Employer you are nominating.

Please provide a name and phone number of the supervisor overseeing consumers employed.

Question Title

* 20. COMMUNITY RESOURCE OF THE YEAR CONTACT INFO: (Please answer Question #21)

Name

Address

City/Town

Email Address

Phone Number

Question Title

* 21. QUESTION: What contributions did the Community Resource organization you are nominating make during the pandemic to support the lives of individuals with developmental disabilities and describe how they went Above and Beyond during those trying times? Please provide additional information the Nomination Committee should know about the organization you are nominating.

Please provide a contact name and phone number of the organization.

Question Title

* 22. OUTSTANDING CLINICAL/MEDICAL SERVICE CONTACT INFO: (Please answer Question #23)

Name

Address

City/Town

Email Address

Phone Number

Question Title

* 23. QUESTION: What contributions has the Clinical / Medical Service you are nominating make during the pandemic to support individuals with disabilities and describe how they went Above and Beyond in supporting the developmental disability community? Please provide additional information the Nomination Committee should know about your nominee.

This can be an individual in the health field or a medical organization. Please provide a name and phone number for the organization.

Question Title

* 24. SERVICE PROVIDER OF THE YEAR CONTACT INFO: (Please answer Question #25)

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 25. An organization funded by San Andreas Regional Center.

QUESTION: What special accommodations did the Service Provider you are nominating make during the pandemic to support the lives of the consumers they serve and describe how they went Above and Beyond during these trying times? Please provide additional information the Nomination Committee should know about the Service Provider you are nominating.

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