download the Nomination
Form as a WORD document
download the Nomination Form as an RTF
doc
Must
be Received by April 30th, 2001
For each nomination please complete the following information. Type
or print clearly.
Nominee's name_________________________________________________________________
(may be an individual, organization, or group)
Address_______________________________________________________________
(home or business-circle one)
City______________________________Prov.__________________PC___________
Telephone # and area code:
(home)_____________________ (work)__________________________
E-mail ________________________
Nominee is: (check one)
[ ] an individual
[ ] an organization
[ ] a group
If organization
or group: Contact name Phone #:
Job title of nominee (if appropriate)_________________________________________
Nominator's name______________________________________________________
Address_____________________________________________________________
City________________________________Prov_________________PC__________
Telephone # and area code:
(home)_____________________ (work)__________________________
E-mail ________________________
Your relationship to nominee (employee, co-worker, friend, etc.)___________________
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Inclusion is people with disabilities and people without disabilities
participating together in all life activities - at school, at work,
at home, at worship, in the community.
This nomination
is in the area of (check one only):
[ ]
Community Inclusion: This nominee has demonstrated
inclusion by creating opportunities in the community for people with
disabilities to be full participants in and contributors to community
events, recreation, leisure, and public venues.
[ ]
Educational Inclusion: This nominee has demonstrated
a commitment to including all of students by implementing practices
so that students with and without disabilities are being educated
together with attention to what is good for all learners.
[ ]
Religious Inclusion: This nominee has demonstrated
commitment to and inclusion of people with disabilities as attendees
and as active participants in worship, in the life of the congregation
and in fellowship. Welcoming practices and physical accommodations
are both important to inclusion.
[ ]
Workplace Inclusion: This nominee has demonstrated
inclusion by supporting and promoting qualified workers with disabilities
through innovative workplace design and/or practice.
[ ]
Outstanding Achievement: This nominee is a champion
of inclusion who demonstrates in various aspects of performance and
life an ongoing, pervasive, and even tireless effort for people with
disabilities to become part of all that goes on in our communities.
Please answer the following. Type or print clearly.
Read all questions before beginning. Use space provided.
1) This nominee deserves recognition for the following reasons:
Page 3
2) Give three
concrete examples of how this nominee supports inclusion of people
with disabilities.
·
·
·
3) How long has the nominee engaged in or promoted inclusive practices?
Have practices changed overtime, if so describe:
Page 4:
4) Give one example of what others can learn from this nominee about
including people with disabilities:
5) Is inclusion
part of the nominee's regular daily operation or job responsibilities?
Yes_____ or No_____
If "yes," please explain.
Note: While it
is not necessary to send any additional information for a nomination,
you may supplement your nomination by including up to five additional
pages that give specifics and supports your nomination as "best
inclusion practice." We cannot return any materials sent. All
materials must clearly indicate, on each piece sent, the nominee's
name, the nominator's name, and date.
Please read the
entire Nomination form before answering any questions. Make your nomination
no later than mid April to ensure it is received by April 30th, 2001.
If you have questions please email dawn@thot.net