**Annual Service Above Self Awards Hosted by San Andreas Regional Center.

Deadline to submit nominations is Friday, September 6, 2019

NOMINATIONS WILL NOT BE ACCEPTED if questions 1 and 2 are not answered.**

1.

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Question Title

* 1. PERSON MAKING THE NOMINATION (Your nomination will not be accepted without the following information about you)

NAME:
ADDRESS:
CITY & ZIP:
PHONE NUMBER:
EMAIL ADDRESS:

Question Title

* 2. ADVOCATE OF THE YEAR (An individual with a developmental disability who advocates for others - Formerly Consumer of the Year Award. This individual must be doing for others not just themselves.

Please answer the following information about the Advocate you are nominating:

Name:
Address:
City & Zip:
Phone Number:
Email Address:

YOU MUST ANSWER THESE TWO QUESTIONS WHEN SUBMITTING YOUR NOMINATION.

Question 1. What contributions has this individual made to advocate for the developmental disability community and describe how their contributions go above and beyond.

Question 2. Please add any other pertinent information you feel the nomination committee should know about the consumer you are nominating.

Question Title

* 3. SPECIAL EDUCATION TEACHER OF THE YEAR - (Kindergarden through 12th Grade). A Special Education Teacher who is in a K thru 12 classroom setting teaching in a Special Education Class. How does this teacher go Above and Beyond their normal teaching expectations.

Please answer the following information about the Special Education Teacher you are nominating:

Name:
School:
Address:
City & Zip:
Phone Number:
Email Address:

YOU MUST ANSWER THESE TWO QUESTIONS WHEN SUBMITTING YOUR NOMINATION.

Question 1. What contributions has this special education teacher made to improve the lives of her/his students and how does she/he go above and beyond their teaching responsibilities.

Question 2. Please add any other pertinent information you feel the nomination committee should know about the teacher you are nominating.

Question Title

* 4. SERVICE PROVIDER OF THE YEAR (An organization vendorized by San Andreas). How does this Service Provider go Above and Beyond in their normal delivery of service expectations.

Please answer the following information about the Service Provider you are nominating:

Name of Vendor:
Contact Person:
Address:
City & Zip:
Phone Number:
Email Address:

YOU MUST ANSWER THESE TWO QUESTIONS WHEN SUBMITTING YOUR NOMINATION

Question 1. What contributions has this service provider made to improve the lives of consumers, their families, and or the developmentally disabled community and describe how their contributions go above and beyond their normal responsibilties and expectations.

Question 2. Please add any other pertinent information you feel the nomination committee should know about the provider you are nominating.

Question Title

* 5. COMMUNITY RESOURCE OF THE YEAR (An organization or group not vendorized by San Andreas)

Please answer the following information about the Community Based Organization you are nominating:

Name of Organization:
Contact Person:
Address:
City & Zip:
Phone Number:
Email Address:

YOU MUST ANSWER THESE TWO QUESTIONS WHEN SUBMITTING YOUR NOMINATION.

Question 1. What services or contributions has this organization made to improve the lives of individuals with developmental disabilities and the disability community.

Question 2. Please add any other pertinent information you feel the nomination committee should know about the organization you are nominating.

Question Title

* 6. EMPLOYER OF THE YEAR - An employer who hires individuals with developmental disabilities. How does this employer go Above and Beyond their normal employment expectations of hiring an individual with a developmental disability.

Please answer the following information about the Employer you are nominating:

Employer:
Name of Manager or Owner:
Address:
City & Zip:
Phone Number:
Email Address:

YOU MUST ANSWER THESE TWO QUESTIONS WHEN SUBMITTING YOUR NOMINATION.

Question 1. What contributions has this employer made to the developmental disability community by hireing an individual with a developmental disability.

Question 2. Please add any other pertinent information you feel the nomination committee should know about the employer you are nominating.

Question Title

* 7. SUPPORT STAFF OF THE YEAR (an individual who works as a Teachers Aide, Direct Care Support Staff, or Service Provider Support Staff) How does this support or service provider staff go Above and Beyond their normal work expectations in helping individuals with developmental disabilities.

Please answer the following information about the Support Staff you are nominating:

Support Staff Name:
Name of Service Provider or Family the person works for:
Address:
City & Zip:
Phone Number:
Email Address:
Name of Supervisor:

YOU MUST ANSWER THESE TWO QUESTIONS WHEN SUBMITTING YOUR NOMINATION.

Question 1. What contributions has this individual made to improve the lives of the consumers they serve and describe how does their work go above and beyond the normal responsibilities and expectations of their job.

Question 2. Please add any other pertinent information you feel the nomination committee should know about the support staff you are nominating.

Question Title

* 8. LEGISLATIVE ADVOCATE OF THE YEAR (can be local, state or federal elected officials or someone who does legislative advocacy)

Please answer the following information about the Advocate you are nominating:

Address:
City & Zip:
Phone Number:
Email Address:
Name of Supervisor:

Question 1. What contributions has this legislator made to improve the lives of individuals with developmental disabilities, their families and the disability community.

Question 2. Name of Legislator / Advocate

Question Title

* 9. OUTSTANDING COMMUNITY SERVICE FROM A VOLUNTEER (Non-Profit Board Members, school volunteers, students, or anyone who volunteers their time (non-paid) to the disability community). How does this individual go Above and Beyond their normal volunteer duties in serving the disability community.

Please answer the following information about the Volunteer you are nominating:

Name:
Address:
City & Zip:
Phone Number:
Email Address:

YOU MUST ANSWER THESE TWO QUESTIONS WHEN SUBMITTING YOUR NOMINATION.

Question 1. What contributions has this individual made to improve the lives of individuals with developmental disabilities, their families, and or the disability community and describe how their contributions go above and beyond.

Question 2. Please add any other pertinent information you feel the nomination committee should know about the individual or organization you are nominating.

Question Title

* 10. OUTSTANDING CLINICAL OR MEDICAL SERVICE - This can be an individual or medical organization in the clinical or medical field. How does this individual go Above and Beyond in serving the disability community in need of clinical or medical services.

Please answer the following information about the Individual or Medical Organization you are nominating:

Name:
Name of contact:
Address:
City & Zip:
Phone Number:
Email Address:

YOU MUST ANSWER THESE TWO QUESTIONS WHEN SUBMITTING YOUR NOMINATION.

Question 1. What contributions has this individual made to serve individuals with developmental disabilities and the disability community.

Question 2. Please add any other pertinent information you feel the nomination committee should know about the individual or medical group you are nominating.