«

»

2013 Nomination Form “Amazing Kids”

Person completing this form:

Title _____________________________________

Name _______________________________________________________________________________________
(First)                                                      (Last)

Address _____________________________________________________________________________________
(Street Address)                                                                 (Town/City)                                     (Zip Code)

Affiliation _____________________________________________________________________________________
(Name)                                                                                      (Town/City)

E-mail __________________________________________________

Telephone ________________________________

 

Youth receiving nomination:

Name & Age __________________________________________________________________________________
(First)                                                                         (Last)                                                (Age)

Address ______________________________________________________________________________________
(Street Address)                                                             (Town/City)                                      (Zip Code)

School ______________________________________________________________________________________
(Name)                                                                                          (Town/City)

E-mail ______________________________________________________________

Telephone _____________________________________

Condition(s): ______________________________________________________________________________
_________________________________________________________________________________________

Activities: _____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Testimonials; how does this young person inspire you with their resiliency, optimism and determination?
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________________

Thank you for taking the time to make a nomination for the Champions Among Children Awards through the Council for Youths with Chronic Conditions (CYCC). You will be notified of the outcome of your nomination prior to the reception in the state capitol on Tuesday, November 19 at 11 a.m. at the Holiday Inn in Concord. The CYCC welcomes nominators, families, friends, and professionals to attend to honor award recipients.