Imagine Awards Nomination Form

This form is to nominate an Individual with a Disability. This award is given to a person with a disability for outstanding personal achievements.

For assistance or questions, please contact:

Development Office
Rauch, Inc.
845 Park Place
New Albany, IN 47150
(812) 945-4063
jspoelker@rauchinc.org

Guidelines: Please be as specific and detailed as possible. The more specific the information, the greater chance your nominee will have to be selected for an Imagine Award. If you would like to provide additional documentation or information, up to two 8 1/2 x 11" size documents can be sent to jspoelker@rauchinc.org

Nominees must work and/or live in Clark, Floyd, Harrison, Scott, or Washington Counties in Indiana or Jefferson County, Kentucky.

*Please note that employees of Rauch, Inc. are not eligible to submit Imagine Awards nominations, but are welcome to encourage others in the community to do so. 

Nominee Contact Information
Nominee's Name *
Nominee's Name
Nominee's Home Phone *
Nominee's Home Phone
Nominee's Work Phone
Nominee's Work Phone
Nominee's Street Address *
Nominee's Street Address
Nominating Entity Contact Information
Nominating Entity's Address *
Nominating Entity's Address
Nominating Entity's Phone *
Nominating Entity's Phone
Award Information
Award Category *
Please check to indicate approval of nominee. *
Rationale for Nomination
The information that you provide will determine if your nominee is selected and is very important to the judges.