The 26th Annual Shine A Light on Child Abuse Prevention Awards Nomination Form
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Shine A Light On Child Abuse Prevention Nomination
Nominee Information
1.
Nominee First AND Last Name:
*
2.
Nominee Agency/Organization:
*
3.
Nominee Job Title:
*
4.
Nominee Email Address:
*
5.
Nominee Work Address:
*
6.
Nominee Phone Number:
*
7.
Nomination Category:
* Check all that apply
*
Business
Behavioral Health
Children and Family Services
Community Based Provider or Organization
Education
Foster Parent
Law Enforcement
Legal
Medical
Probation
Public Health
Volunteer
Other
Other
8.
Describe Nominee's Qualifications *
In addition to providing the information above, please include the work the nominee performs, their unique contributions that go beyond the duties of their job and their special relationships with children and youth.
(Minimum 300 words. Maximum 800 words)
Nominations with less than 300 words will not be accepted.
Please provide your write-up in the space provided below.
*
Nominator Information
Please provide your information below, so that we can contact you with any questions.
9.
Nominator First AND Last Name:
*
10.
Nominator Address:
*
11.
Nominator Email Address:
*
12.
Nominator Phone Number:
*
13.
Nominator Agency/Organization:
*