Child Advocate of the Year
NOMINATION FORM

*Your Information*

First Name		Last Name		Phone Number
Address		City		State		Zip Code
Email

In the space below, please complete the information about the individual or business you are nominating:

*Nominee Information*

Person or Business:		Phone Number		Email
Address: (Home or Work)		City		State		Zip Code

*Category*

Volunteer	Government	Business or Business Leader
Education	Other

Please list some of this individual's/business's accomplishments as a child advocate: *

Why does this individual/business deserve the Child Advocate of the Year Award? *

How has this individual/business gone above and beyond to make a difference in the life of a child or children? *

In 100 words or less, please include any other information that may help the selection committee realize the impact of this individual's/business's efforts. *