Nomination Form

Nominee Information

Nominee First Name *

Nominee Last Name *

Age / Birthdate *

City / State *

Email *

Phone *

Organization or Initiative (if applicable)

Social Media / Website (if any)

Nominator Information

Your Full Name *

Your Relationship to the Nominee *

How long have you known the nominee? *

Your Email *

The Work They Are Doing

Describe the work or service the nominee provides in less than 300 words. *

What problem, need, or gap does their work address?

How long has the nominee been doing this work?

How did they get their start? Tell us their origin story.

Impact

Approximately how many individuals has this person directly impacted?

Please explain how you estimated this number.

Describe one or two examples of how their work has changed someone's life or improved a community.

What measurable outcomes or results have come from their work?

Personal Commitment

Approximately how many hours per week does the nominee spend on this work?

Has the nominee invested their own money into this work?

Optional: Please describe what they funded personally.

Has the nominee raised money for this work? If so, how, how much and from whom?

Character & Values

Rank the following values as they best describe the nominee. Select the one you believe to be the most important to this nominee.

Provide one example that shows each of top three (3) values in action.

“Unsung” Status

Has the nominee received any public recognition for this work?

Why do you believe this person is an “unsung hero”? *

Story & Visibility

If selected, would the nominee be willing to participate in:

Podcast appearance/recorded interview

Social media promotions of their efforts

Short documentary video

Community event recognition

Live workshop appearances when requested

What makes this nominee’s story compelling or inspiring? *

What do you believe the future holds for this nominee?

Supporting Evidence

Links or supporting materials (optional)

Is there anyone else who can verify this work? Please supply 2 references to support this application

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