2019 Imagine Awards Nomination Form

Guidelines

Please print or type all information. Be as specific and detailed as possible. The more legible and specific the information, the greater chance your nominee will have to be selected for an Imagine Award. The references you provide may be contacted as a part of the judging process.

 Nominees must work and/or live in Clark, Floyd, Harrison, Scott or Washington Counties in Indiana or Jefferson County, Kentucky. A description of the award categories is listed below.

·         2019 Imagine Award for an Individual with a Disability. This award is given to a person with a disability for outstanding personal achievements.

·         2019 Imagine Award for a Community Leader/Citizen/Volunteer. This award acknowledges those whose actions have had a positive impact upon the lives of persons with disabilities. The individual is recognized for his/her ongoing commitment to improve the lives of persons with disabilities through personal and/or professional efforts.

·         2019 Imagine Award for a Business/Organization. This award is given to a business or organization that has shown a consistent commitment to employ or enhance the lives individuals with disabilities in the workplace and in the community.

Nominee

Name/Business:____________________________________________________________________________

Address:____________________________

City:_____________________

State:______

Zip:_________

Contact:_________________________

Home Phone:_____________

Work Phone:___________________

Nominee’s Place of Employment:_______________________________

E-mail:________________________

Nominating Organization/Individual

Name/Business:_____________________________________________________________________________

 Address:____________________________

 City:____________________

State:______

Zip:__________

Phone:______________________

 Fax:___________________

E-mail :________________________

 Award Category (circle one):    Individual                              Community Leader                     Business

 Signature of person making the nomination:________________________________________________________

 I consent to the judging process and, if selected as a winner, will attend the 2019 Imagine Awards at Horseshoe Southern Indiana on 3/2/2019 to accept the honor.

 Signature of nominee:__________________________________________________________________________


COMMUNITY LEADER OR BUSINESS NOMINATION QUESTIONS

Rationale for making an Imagine Awards Nomination

 The information that you provide will determine if your nominee is selected and is very important to the judges.

 Instructions: Please print or type all information, keep answers short and concise, and use no more than two pages to answer the four questions provided. Two additional pages of attachments may be supplied as supporting documentation.

 IMPORTANT! THE FOLLOWING QUESTIONS ARE FOR NOMINATING A COMMUNITY LEADER OR BUSINESS. PLEASE SEE THE FOLLOWING PAGE IF NOMINATING AN INDIVIDUAL WITH A DISABILITY.

 1. Briefly describe your nominee’s experiences working with and/or advocating for individuals with disabilities.

 

 

 

2. What activities exemplify your nominee’s efforts to help build “a community where everyone belongs”?

 

 

 

 3. List any other civic activities in which your nominee may be or has been involved.

 

 

 

 4. Provide a brief synopsis summarizing why your nominee should be considered for an Imagine Award.

 

 

 

   Please submit no later than December 14, 2018 to:

Development Office

Rauch, Inc.

845 Park Place

New Albany, IN  47150

Phone: 812-945-4063 - Fax: 812-941-8820

jspoelker@rauchinc.org

Thank you for taking the time to nominate a deserving individual or organization.


INDIVIDUAL WITH A DISABILITY NOMINATION QUESTIONS

 

Rationale for making an Imagine Awards Nomination

 The information that you provide will determine if your nominee is selected and is very important to the judges.

 Instructions: Please print or type all information, keep answers short and concise, and use no more than two pages to answer the four questions provided. Two additional pages of attachments may be supplied as supporting documentation.

 

IMPORTANT! THE FOLLOWING QUESTIONS ARE FOR NOMINATING AN INDIVIDUAL WITH A DISABILITY. PLEASE SEE THE PRECEDING PAGE IF NOMINATING A COMMUNITY LEADER OR BUSINESS.

 1. Briefly describe your nominee’s diagnosed disability or disabilities and how this has impacted his or her life.

 

 

 2.  List activities and accomplishments of your nominee.

 

 

 3. How does your nominee help build “a community where everyone belongs”?

 

 

4. Provide a brief synopsis summarizing why your nominee should be considered for an Imagine Award.

  

 

Please submit no later than December 14, 2018 to:

Development Office

Rauch, Inc.

845 Park Place

New Albany, IN  47150

Phone: 812-945-4063 - Fax: 812-949-0830

jspoelker@rauchinc.org

Thank you for taking the time to nominate a deserving individual or organization.