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Wesley Rice Youth Advocate of the Year Award Nomination Form
This award is presented to a youth with a disability, aged 7 to 26, who stands out as a strong self-advocate in their school, home, or community. The nominee must exhibit leadership by confidently speaking up for themselves and others, demonstrating courage and resilience in advocating for their rights and needs. This individual should serve as a positive role model for other young people with disabilities, inspiring them to take pride in their voices and abilities while fostering a sense of empowerment and inclusion within their communities.
Date
Nominees Name
*
First Name
Last Name
Nominees Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nominees County
*
Nominees E-mail
*
Nominees Phone Number
*
-
Area Code
Phone Number
Nominees Cell Number
-
Area Code
Phone Number
Youth's age
Parent and/or Guardians Name:
*
Short essay describing why this nominee is deserving of recognition.
*
Please Note: Do not give confidential information about the youth unless permission has been given from nominee and/or guardian.
0/250
Include a photo of the nominee (jpg format)
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Nominated by:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
CLICK HERE to submit your nomination
Should be Empty: