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Wesley Rice Youth Advocate of the Year Award Nomination Form
This award is given to a youth with a disability between the ages of 7 and 26 who is a strong self-advocate at school, home or in the community. Nominee must demonstrate leadership by speaking up for themselves and others and is positive role model for young people with disabilities. All nominees will be considered and the recipient chosen to receive the award will be contacted for further information.
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: