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Celebrate Our Carers - Nomination Form

THIS form is to nominate a direct care worker you feel should win an award at our event!

If you have not registered for the event, please visit: here. THIS form is to nominate a direct care worker that you feel should win one of three Angel Awards being given out during the Celebrate Our Carers event. Every person nominated will receive a small token of appreciation on the day of the event. Nominations will end on Monday, September 25, 2023 (Winners of an Angel award do not need to be present to win, but attendance is deeply appreciated!). For answered questions, or if you need an alternative format to complete this form, please email jenniferkucera134@gmail.com. 
1.What is your name? (First and Last)(Required.)
2.What is your cell phone number? (If you do not have a cell phone, just leave this question blank)
3.What is your email address?(Required.)
4.Do you use direct care workers to assist you in your daily care needs?(Required.)
5.Do you have a Waiver?
6.Which Waiver or program are you on?
7.Would you like to Nominate a direct care worker to be honored at the Celebrate Our Carers event, taking place on September 28, 2023, at Ohio's Statehouse?
8.What is the first and last name of Direct Care worker you want to nominate?
9.What type of Direct Care worker are they? (example: caregiver, nurse)
10.Please choose the best answer that finishes this sentence: This direct care worker...
11.Please choose the best answer that finishes this sentence: This direct care worker assists...
12.Why are you nominating them? Explain WHY you think they should win 1 of the 3 Angel awards at the Celebrate Our Carers event? What makes them a great direct care worker?
13.Can you provide contact information for the person you are nominating?
14.Please provide a phone number for the person you are nominating. If you do not know their phone number, type in NA.
15.Please provide an email address for the person you are nominating. If you do not know their email address, type in NA.
16.Is there anything else we should know about the person you have nominated? Please tell us here.
17.Any other comments or questions of concern?  Please let us know here.