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San Andreas Regional Centers
25th Annual Service Above Self Awards Dinner

Nomination Deadline - Friday, September 1st

1. Default Section

Question Title

* 1. PERSON MAKING THE NOMINATION

Name

Address

City/Town

Email Address

Phone Number

Question Title

* 2. ADVOCATE OF THE YEAR: QUESTION - How has the Advocate (an individual with a Developmental Disability) you are nominating go Above and Beyond in advocating for others with disabilities?

Name

Address

City/Town

Email Address

Phone Number

Question Title

* 3. ADVOCATE OF THE YEAR: Leave Written Response here for Advocate of the Year being Nominated. Please share detailed information that will help the Nomination Committee know more about the Advocate you are nominating.

Question Title

* 4. EMPLOYEE OF THE YEAR: QUESTION - How does the Employee (an individual with a Developmental Disability) you are nominating go Above and Beyond with their job duties? Please include additional information the Nomination Committee should know about the Employee you are nominating. Please provide a name and phone number of the supervisor managing the individual being nominated.

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 5. EMPLOYEE OF THE YEAR: Leave Written Response here for Employee of the Year being Nominated. Please share detailed information that will help the Nomination Committee know more about the Employee you are nominating.

Question Title

* 6. SPECIAL EDUCATION TEACHER OF THE YEAR: QUESTION - What contributions does the Special Education Teacher you are nominating make to advocate for students and describe how they go Above and Beyond to help students achieve academic milestones?

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 7. SPECIAL EDUCATION TEACHER OF THE YEAR: Leave Written Response below for Special Education Teacher of the Year being Nominated. Please share detailed information that will help the Nomination Committee know more about the Teacher you are nominating.

Question Title

* 8. SUPPORTING LIVING STAFF OF THE YEAR: QUESTION - How does the Supported Living Staff you are nominating go Above and Beyond in supporting the individuals they serve?

Please provide the SLS supervisors name and phone number.

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 9. SUPPORTING LIVING STAFF OF THE YEAR: Leave Written Response below for Supported Living Staff being Nominated. Please share detailed information that will help the Nomination Committee know more about the SLS person you are nominating.

Question Title

* 10. RESIDENTIAL STAFF OF THE YEAR: QUESTION - How does the Residential Staff you are nominating go Above and Beyond in supporting the individuals they serve?

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 11. RESIDENTIAL STAFF OF THE YEAR: Leave Written Response below for Residential Staff of the Year being Nominated. Please include detailed information that will help the Nomination Committee know more about the Residential Staff you are nominating.

Question Title

* 12. INDEPENDENT LIVING STAFF OF THE YEAR: QUESTION - How does ILS person you are nominating go Above and Beyond in supporting the individuals they serve?

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 13. INDEPENDENT LIVING STAFF OF THE YEAR: Leave Written Response below for Independent Living Staff you are Nominating. Please share detailed information that will help the Nomination Committee know more about the ILS person you are nominating.

Question Title

* 14. DIRECT CARE / SUPPORT STAFF OF THE YEAR: QUESTION - How does the Direct Care / Support Staff you are nominating go Above and Beyond in supporting the individuals they serve?

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 15. DIRECT CARE / SUPPORT STAFF OF THE YEAR: Leave Written Response below for Direct Care / Support Staff you are Nominating. Please share detailed information that will help the Nomination Committee know more about the person you are nominating.

Question Title

* 16. VOLUNTEER OF THE YEAR: QUESTION - What contributions has the Volunteer you are nominating done to support the lives of individuals with developmental disabilities?

Name

Address

City/Town

Email Address

Phone Number

Question Title

* 17. VOLUNTEER OF THE YEAR: Leave Written Response below for the Volunteer you are Nominating. Please share detailed information that will help the Nomination Committee know more about the person you are nominating.

Question Title

* 18. EMPLOYER OF THE YEAR (A business who employs individuals with disabilities) QUESTION - What accommodations does the Employer make and how do they go Above and Beyond to keep individuals with developmental disabilities employed?

Please provide a name and phone number of the supervisor.

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 19. EMPLOYER OF THE YEAR: Leave Written Response below for Employer being Nominated. Please share detailed information that will help the Nomination Committee know more about the employer you are nominating.

Question Title

* 20. COMMUNITY RESOURCE OF THE YEAR: QUESTION (A Non-Profit Organization in the community) - What contributions has the Community Resource Organization you are nominating support the lives of individuals with developmental disabilities and describe how they go Above and Beyond?

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 21. COMMUNITY RESOURCE OF THE YEAR: Leave Written Response below for the Community Resource Organization being Nominated. Please share detailed information that will help the Nomination Committee know more about the organization you are nominating.

Question Title

* 22. OUTSTANDING CLINICAL/MEDICAL SERVICE: QUESTION - What contributions did 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?

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 23. OUTSTANDING CLINICAL / MEDICAL SERVICE: Leave Written Response below for Clinical / Medical Service being Nominated. Please share detailed information that will help the Nomination Committee know more about the person / medical service you are nominating.

Question Title

* 24. SERVICE PROVIDER OF THE YEAR (An organization funded by San Andreas Regional Center): QUESTION - What special accommodations has the Service Provider done that support them in going Above and Beyond in serving individuals with developmental disabilities?

Name

Company

Address

City/Town

Email Address

Phone Number

Question Title

* 25. SERVICE PROVIDER OF THE YEAR: Leave Written Response below for the Service Provider being Nominated. Please share detailed information that will help the Nomination Committee know more about the Service Provider you are nominating.

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Question Title

* 1. PERSON MAKING THE NOMINATION

Question Title

* 2. ADVOCATE OF THE YEAR: QUESTION - How has the Advocate (an individual with a Developmental Disability) you are nominating go Above and Beyond in advocating for others with disabilities?

Question Title

* 3. ADVOCATE OF THE YEAR: Leave Written Response here for Advocate of the Year being Nominated. Please share detailed information that will help the Nomination Committee know more about the Advocate you are nominating.

Question Title

Question Title

* 5. EMPLOYEE OF THE YEAR: Leave Written Response here for Employee of the Year being Nominated. Please share detailed information that will help the Nomination Committee know more about the Employee you are nominating.

Question Title

* 6. SPECIAL EDUCATION TEACHER OF THE YEAR: QUESTION - What contributions does the Special Education Teacher you are nominating make to advocate for students and describe how they go Above and Beyond to help students achieve academic milestones?

Question Title

* 7. SPECIAL EDUCATION TEACHER OF THE YEAR: Leave Written Response below for Special Education Teacher of the Year being Nominated. Please share detailed information that will help the Nomination Committee know more about the Teacher you are nominating.

Question Title

* 8. SUPPORTING LIVING STAFF OF THE YEAR: QUESTION - How does the Supported Living Staff you are nominating go Above and Beyond in supporting the individuals they serve?Please provide the SLS supervisors name and phone number.

Question Title

* 9. SUPPORTING LIVING STAFF OF THE YEAR: Leave Written Response below for Supported Living Staff being Nominated. Please share detailed information that will help the Nomination Committee know more about the SLS person you are nominating.

Question Title

* 10. RESIDENTIAL STAFF OF THE YEAR: QUESTION - How does the Residential Staff you are nominating go Above and Beyond in supporting the individuals they serve?

Question Title

* 11. RESIDENTIAL STAFF OF THE YEAR: Leave Written Response below for Residential Staff of the Year being Nominated. Please include detailed information that will help the Nomination Committee know more about the Residential Staff you are nominating.

Question Title

* 12. INDEPENDENT LIVING STAFF OF THE YEAR: QUESTION - How does ILS person you are nominating go Above and Beyond in supporting the individuals they serve?

Question Title

* 13. INDEPENDENT LIVING STAFF OF THE YEAR: Leave Written Response below for Independent Living Staff you are Nominating. Please share detailed information that will help the Nomination Committee know more about the ILS person you are nominating.

Question Title

* 14. DIRECT CARE / SUPPORT STAFF OF THE YEAR: QUESTION - How does the Direct Care / Support Staff you are nominating go Above and Beyond in supporting the individuals they serve?

Question Title

* 15. DIRECT CARE / SUPPORT STAFF OF THE YEAR: Leave Written Response below for Direct Care / Support Staff you are Nominating. Please share detailed information that will help the Nomination Committee know more about the person you are nominating.

Question Title

* 16. VOLUNTEER OF THE YEAR: QUESTION - What contributions has the Volunteer you are nominating done to support the lives of individuals with developmental disabilities?

Question Title

* 17. VOLUNTEER OF THE YEAR: Leave Written Response below for the Volunteer you are Nominating. Please share detailed information that will help the Nomination Committee know more about the person you are nominating.

Question Title

* 18. EMPLOYER OF THE YEAR (A business who employs individuals with disabilities) QUESTION - What accommodations does the Employer make and how do they go Above and Beyond to keep individuals with developmental disabilities employed? Please provide a name and phone number of the supervisor.

Question Title

* 19. EMPLOYER OF THE YEAR: Leave Written Response below for Employer being Nominated. Please share detailed information that will help the Nomination Committee know more about the employer you are nominating.

Question Title

* 20. COMMUNITY RESOURCE OF THE YEAR: QUESTION (A Non-Profit Organization in the community) - What contributions has the Community Resource Organization you are nominating support the lives of individuals with developmental disabilities and describe how they go Above and Beyond?

Question Title

* 21. COMMUNITY RESOURCE OF THE YEAR: Leave Written Response below for the Community Resource Organization being Nominated. Please share detailed information that will help the Nomination Committee know more about the organization you are nominating.

Question Title

* 22. OUTSTANDING CLINICAL/MEDICAL SERVICE: QUESTION - What contributions did 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?

Question Title

* 23. OUTSTANDING CLINICAL / MEDICAL SERVICE: Leave Written Response below for Clinical / Medical Service being Nominated. Please share detailed information that will help the Nomination Committee know more about the person / medical service you are nominating.

Question Title

* 24. SERVICE PROVIDER OF THE YEAR (An organization funded by San Andreas Regional Center): QUESTION - What special accommodations has the Service Provider done that support them in going Above and Beyond in serving individuals with developmental disabilities?

Question Title

* 25. SERVICE PROVIDER OF THE YEAR: Leave Written Response below for the Service Provider being Nominated. Please share detailed information that will help the Nomination Committee know more about the Service Provider you are nominating.

* 8. SUPPORTING LIVING STAFF OF THE YEAR: QUESTION - How does the Supported Living Staff you are nominating go Above and Beyond in supporting the individuals they serve?

Please provide the SLS supervisors name and phone number.

* 18. EMPLOYER OF THE YEAR (A business who employs individuals with disabilities) QUESTION - What accommodations does the Employer make and how do they go Above and Beyond to keep individuals with developmental disabilities employed?

Please provide a name and phone number of the supervisor.