Community Leader Award

Hamilton Relay recognizes an individual in each Hamilton Relay contracted state who is Deaf, DeafBlind, hard of hearing, late-deafened or who has difficulty speaking and demonstrates strong leadership and volunteerism within the community. Additionally, an individual or organization that demonstrates leadership and volunteerism in the Deaf, DeafBlind, hard of hearing or speech difference community may be nominated for this award.

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Name of Nominee or Organization *

associations, made additional

Nominee or Organization Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Nominee or Organization Phone

Is this phone hearing assisted?

• Not Known
• Voice
• TTY
• Captioned Telephone
• Videophone (VP)
• Other

Other Hearing Assist

Email Address

How has the nominee been active and-or made an impact in the community? *

Please focus primarily on providing information pertaining to the volunteer efforts and accomplishments completed beyond regular job duties.

List the names of associations, organizations, clubs or other activities in which your nominee has been involved. Include position(s) held, term length and any other pertinent details. *

If nominating an organization, list work and accomplishments that have made an impact the Deaf, hard of hearing, DeafBlind and/or speech difference communities.

What are the strongest points about the nominee? *

Please feel free to include additional information as needed.

Please list two references (other than yourself) and their contact information.

Reference 1 Name *

First

Last

Reference 1 Phone

Reference 1 Email *

Reference 2 Name *

First

Last

Reference 2 Phone

Reference 2 Email *

Please include your contact information.

Your Name *

First

Last

Your Phone *

Your Email *

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