SHINE BRIGHT DREAM BIG BLACK-TIE TEEN GALA NOMINATION FORM

Nomination Form: Shine Bright Dream Big Black Tie Gala

Purpose: This form is designed for individuals to nominate teens between the ages of 13 and 17, who have continued to thrive despite their circumstances. The teen you nominate may be selected to attend The Black- Tie Gala, a special event created to honor and celebrate their resilience, strength and bravery.

Event date and time: July 26, 2025 5pm-9pm

Location: Hilton Hotel Raleigh, NC.

Note: Nominations forms are being accepted Country Wide and are not specific to North Carolina. Event day activities, clothing and styling will all be provided at no cost to selected nominee's (more details will be provided after nominee's are selected).

Deadline for nominations has been extended to July 5, 2025

One submission per household
Presented by: Connecting Villages Worldwide Non-profit 501c3

Check out our website for more information www.connectingvillagesworldwide.org
Nominators Full Name*
Relationship to Nominee: (Please indicate your connection to the teen you are nominating, such as teacher, mentor, counselor, family member, etc
Relationship To Nominee*
Your Phone Number*
Your Email Address*
example@example.com
(Please share as much detail as you can about the teen you are nominating)
Full Name of Nominee*
Age of Nominee (Must be between the ages of 13 and 17)*
Date of Birth*

MonthDayYear
Date
Gender optional
School Name if applicable
Grade if applicable
Share a brief overview of the Nominee's Story and why they deserve this special evening of recognition, inspiration and fun. Share the challenges they've faced, and any impactful moments that reflect their strength and resilience. Please do not provide intimate details about their experiences. (200 word maximun)*
What specific qualities or characteristics make this teen truly exceptional? These might include their perseverance, kindness, leadership or any other qualities that show their remarkable character*
Nominee's Talents and Achievements: This section allows you to highlight the teen's unique qualities and accomplishments beyond their challenges. Please share any personal talents, passions, or goals they have pursued despite their difficulties.*
If your nominee is selected, would you be present on the day of the Gala, and would you like to share any personal messages of encouragement or recognition?*

YesNo
By submitting this form, I affirm that the information I've provided is accurate and truthful to the best of my knowledge. I understand that this nomination will be reviewed by a selection committee, and I give my consent for the nominee to be considered for the Black Tie Gala. I also understand that if selected, the teen's story and achievements may be shared in the context of the event.
Nominators Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Presented by: Connecting Villages Worldwide Non-profit 501c3