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San Andreas Regional Center's
27th Annual Service Above Self Awards Dinner
Saturday, October 25, 2025
Villa Ragusa, 35 South 2nd Street, Campbell, CA
Nomination Deadline - Friday, August 29th
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1.
NAME OF PERSON MAKING NOMINATION
(Required.)
Name:
*
Address:
*
City:
*
County:
Email Address:
Confirm Email Address:
*
Phone Number:
*
2.
ADVOCATE OF THE YEAR: (Please add additional information on Q3)
An Individual with a Developmental Disability Going Above & Beyond Advocating for the Disability Community.
Name of Advocate:
Home Address:
City:
County
Phone Number:
Email Address:
3.
ADVOCATE OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Advocate of the Year you are nominating. What has the Advocate you are nominating done to go Above & Beyond in supporting the disability community? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
4.
EMPLOYEE OF THE YEAR: (Please add additional information on Q5)
An Individual with a Developmental Disability Going Above & Beyond in their Job Responsibilities.
Employee Name:
Home Address:
City:
Phone Number:
Email Address:
Employer:
Years Employed:
Supervisor Name:
Supervisor Email Address:
Supervisor Phone Number:
5.
EMPLOYEE OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Employee of the Year you are nominating. What contributions has the employee you are nominating done to go Above & Beyond in their work responsibilities? Please share additional information the Nomination Committee should know about this individual that will help support nomination?
6.
SPECIAL EDUCATION TEACHER OF THE YEAR
: (Please add additional information on Q7)
A Special Education Teacher working with Students K thru 12 Going Above & Beyond by Exceeding they're Teaching Expectations.
Teachers Name:
School:
School District:
Years Teaching:
Grade:
Email Address:
Phone Number:
Principal's Name:
School Phone Number:
7.
SPECIAL EDUCATION TEACHER OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Special Education Teacher you are nominating. What contributions have they made in going Above & Beyond with educating and supporting students in the classroom? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
8.
SPECIAL EDUCATION AIDE / SUPPORT STAFF OF THE YEAR
: (Please add additional information on Q9)
A Special Education Aide / Support Staff working with Students K thru 12 Going Above & Beyond by exceeding their job expectations in the classroom.
Name:
School:
School District:
Years Being an Aide:
Grade:
Email Address:
Phone Number:
Teachers Name:
Principal's Name:
School Phone Number:
9.
SPECIAL EDUCATION AIDE / SUPPORT STAFF OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Special Education Aide / Support Staff you are nominating. What contributions have they made in going Above & Beyond with educating and supporting students in the classroom? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
10.
SERVICE PROVIDER OF THE YEAR: (Please add additional information on Q11)
An Organization Vendorized / Funded by San Andreas Regional Center. (Please Note: Nominations will Not be accepted by Vendors who Nominate themselves)
Name of Service Provider:
Name of Administrator / Supervisor:
Address:
City:
Email Address:
Phone Number:
11.
SERVICE PROVIDER OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Service Provider you are nominating. What special accommodations does the Service Provider make to support consumers and describe how they go Above and Beyond in serving individuals with developmental disabilities? Please share additional information the Nomination Committee should know about the service provider that will support your nomination?
12.
SERVICE PROVIDER SUPPORT STAFF OF THE YEAR: (Please add additional information on Q11)
Service Provider Support Staff going Above & Beyond in supporting consumers.
Name of Service Provider:
Name of Administrator / Supervisor:
Address:
City:
Email Address:
Phone Number:
13.
SERVICE PROVIDER SUPPORT STAFF OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Service Provider Support Staff you are nominating. What special accommodations has the staff member made to support consumers and describe how they go Above and Beyond in serving individuals with developmental disabilities? Please share additional information the Nomination Committee should know about the service provider staff your nominating?
14.
EARLY START STAFF OF THE YEAR: (Please add additional information on Q12)
Staff providing Early Start Services in a program designed for kids 0 to 3.
Name:
Phone Number:
Email:
Employer / Service Provider:
Years Employed:
Service Provider Address:
City:
Supervisor Name:
Supervisor Phone Number:
Supervisor Email:
15.
EARLY START STAFF OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Early Start Staff you are nominating. What contributions has the Early Start Staff done to go Above & Beyond in supporting the consumers they serve? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
16.
SUPPORTIVE LIVING SERVICES (SLS) STAFF OF THE YEAR: (Please add additional information on Q15)
Supportive Living Services (SLS) Staff Going Above & Beyond by Exceeding their Job Duties.
Name:
Phone Number:
Email:
Employer / Service Provider:
Years Employed:
Service Provider Address:
City:
Supervisor Name:
Supervisor Phone Number:
Supervisor Email:
17.
SUPPORTING LIVING SERVICES (SLS) STAFF OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the SLS Staff you are nominating. What contributions has the SLS Staff done to go Above & Beyond in supporting the consumers they serve? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
18.
INDEPENDENT LIVING SERVICES (ILS) STAFF OF THE YEAR:
Independent Living Services (ILS) Staff Going Above & Beyond by Exceeding their Job Duties.
Name:
Phone Number:
Email:
Employer / Service Provider:
Years Employed:
Service Provider Address:
City:
Supervisor Name:
Supervisor Phone Number:
Supervisor Email:
19.
INDEPENDENT LIVING SERVICES (ILS) STAFF OF THE YEAR WRITTEN RESPONSE: (Please add additional information on Q18)
Please provide information below about the ILS Staff you are nominating. What contributions has the ILS Staff done to go Above & Beyond in supporting the consumers they serve? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
20.
RESIDENTIAL STAFF OF THE YEAR:
Residential Staff Going Above & Beyond by Exceeding their Job Duties.
Name:
Phone Number:
Email:
Employer / Service Provider:
Years Employed:
Service Provider Address:
City:
Supervisor Name:
Supervisor Phone Number:
Supervisor Email:
21.
RESIDENTIAL STAFF OF THE YEAR:
Please provide information below about the Residential Staff you are nominating. What expectations has the Residential Staff done to go Above & Beyond in supporting the consumers they serve? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
22.
SUPPORTIVE EMPLOYMENT STAFF OF THE YEAR: (Please add additional information on Q21)
Supportive Employment Staff Going Above & Beyond by Exceeding their Job Duties.
Name:
Phone Number:
Email:
Employer / Service Provider:
Years Employed:
Service Provider Address:
City:
Supervisor Name:
Supervisor Phone Number:
Supervisor Email:
23.
SUPPORTED EMPLOYMENT STAFF OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Supportive Employment Staff you are nominating. What expectations has the Residential Staff done to go Above & Beyond in supporting the consumers they serve? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
24.
VOLUNTEER OF THE YEAR: (Please add additional information on Q23)
An individual who volunteers their time supporting individuals with developmental disabilities.
Name:
Phone Number:
Email:
Volunteer Location:
Years Volunteering:
Volunteer Location Address:
City:
Supervisor Name:
Supervisor Phone Number:
Supervisor Email:
25.
VOLUNTEER OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Volunteer you are nominating. What support was made to individuals with developmental disabilities and how did they go Above & Beyond in their volunteer duties? Please share additional information the Nomination Committee should know about this individual that will support your nomination?
26.
EMPLOYER OF THE YEAR: (Please add additional information on Q25)
An employer who employs individuals with developmental disabilities.
Name of Business:
Supervisor Name:
Supervisor Phone Number:
Supervisor Email:
Address:
City:
How Many Individuals with IDD are Employed:
How long have they been Employing Individuals with IDD?
27.
EMPLOYER OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Employer you are nominating. What accommodations has the employer made to keep individuals with developmental disabilities employed? Please share additional information the Nomination Committee should know about the employer that will support your nomination?
28.
COMMUNITY RESOURCE OF THE YEAR QUESTION
: (Please add additional information on Q27)
A Program or Non-Profit Organization Not Funded by San Andreas Regional Center providing free services in the community.
Name of Organization:
Supervisor Name:
Supervisor Phone Number:
Supervisor Email:
Address:
City:
How Many Individuals with IDD are Supported?
How long have they been Supporting Individuals with IDD?
29.
COMMUNITY RESOURCE OF THE YEAR WRITTEN RESPONSE:
Please provide information below about the Community Resource Organization you are nominating. How have they gone Above and Beyond in supporting the developmental disability community? Please share additional information the Nomination Committee should know about the organization that will support your nomination?
30.
OUTSTANDING COMMUNITY SERVICE & SUPPORT: (Please add additional information on Q29)
An Individual providing direct services and supports to individuals with developmental disabilities.
Name:
Service Provider / Organization:
Phone Number:
Email:
Name of Supervisor:
Supervisor Phone Number:
Address:
City:
31.
OUTSTANDING COMMUNITY SERVICE & SUPPORT:
Please provide information below about the individual you are nominating. Please share additional information the Nomination Committee should know about this individual / organization that will support your nomination?
