CITIZEN RECOGNITION PROGRAM NOMINATION FORM

Transcription

1 CITIZEN RECOGNITION PROGRAM NOMINATION FORM 2017

2 Nominate an outstanding resident of Wood Buffalo for the Citizen Recognition Program Do you know an exceptional individual or group that goes above and beyond to make the region a better place to live? Wood Buffalo residents are invited to nominate fellow individuals or groups for their contributions to improve the community. The Citizen Recognition Program was created to acknowledge outstanding individuals or groups that make a significant contribution to, or positive impact on Wood Buffalo residents. Residents that have lived in Wood Buffalo for at least 12 consecutive months are eligible to be nominated for the Program. Nominations are based on overall achievement, impact and/or contribution to the region. There is no age limit for nominees to be eligible. Individuals and groups may be nominated every year, but may only receive special recognition once in their lifetime. Each nominee, their nominator and special guests will be invited to the annual event scheduled for Thursday, January 25, All nominees will be celebrated for their outstanding contributions, and Mayor and Councillors will select up to eight (8) recipients from all nominations to receive special recognition during the event. The nomination deadline is Saturday, September 30, Here s your chance to recognize someone in the community whose efforts really stand out. More information and nomination packages can be found at or by phoning Please ensure that you have collected the following information before you begin: 1. Contact information on the individual/group being nominated. 2. A 500 word nomination letter. 3. Two support letters to endorse the nomination. 4. Twelve high resolution photos of the nominee (preferably doing what they have been nominated for). 5. Your contact information. 6. The signed declaration letter (available as a PDF download on our website).

3 Nomination Form Step 1 Information on the Individual/Group being Nominated *Nominee Name (First, Middle, Last) or Group Name: *Preferred Name: (or group contact name) Current Address: City: Province: Postal Code: Step 2 The Nomination Please tell us about the nominee in a 500 word (maximum) document. Make certain to include: Why you believe the nominee deserves to be recognized What are the nominee s contributions to the region What makes the nominee a community ambassador/advocate Be creative and tell us their story! Themes for the awards are based on the Regional Municipality of Wood Buffalo s vision, mission and values as outlined in the Municipal Development Plan. Examples include, but are not limited to: o Collaboration o Community Spirit o Culture and Arts o Diversity o Economic Resilience o Effective Partnerships o Empowerment o Historical Preservation o Innovation o Inspiration o Regional Pride o Responsible Development o Responsible Environmental Practices o Safety o Sport and Recreation o Sustainability o Vibrant Cultural Diversity o Volunteerism o Wellness *Letter of Nomination (Please attach to completed nomination package)

4 Step 3 Support Letters for the Nomination Supporter #1 *Supporter Name: Organization: (if applicable) Relation to Nominee: *Letter of Support: (500 word maximum) (please attach to completed nomination package) Supporter #2 *Supporter Name: Organization: (if applicable) Relation to Nominee: *Letter of Support: (500 word maximum) (please attach to completed nomination package)

5 Step 4 Additional Documentation Please include the following: Twelve high quality pictures of the nominee : *( submissions can be a maximum of 8mb) Any additional documentation: (certificates, media articles, awards, additional support, etc) The photos can be ed to champions@rmwb.ca Please note: This application is not deemed complete until these photos are received. The additional documentation can be ed to champions@rmwb.ca or attached to the completed nomination package Step 5 Information about YOU, the Nominator *Nominator Name: (First, Middle, Last) Organization: (if applicable) Current Address: City: Province: Postal Code: I heard about this program through; o friend, o newsletter, o newspaper, o radio, o social media, o magazine, o community space advertisement, o other (please specify)

6 Step 6 Declaration Please note: The nominator must have the consent of the nominee. If the nominee is deceased or under the age of majority, you must obtain the written consent of a family member or guardian. The personal information on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act. The information provided will be used to process your nomination and as contact information. If you have any questions about the collection or use of this information, please contact Community Strategies, in person at Jubilee Centre (9909 Franklin Ave.), champions@rmwb.ca, or call *Nominator Declaration By submitting this nomination, I confirm that the information provided is true and accurate. I understand that any false statements or other misrepresentations made on this nomination may result in the nomination being disqualified. Nominator Name (please print) Signature Date *Nominee Declaration I hereby certify that I consent to being nominated for the Citizen Recognition Program. I consent to my information and image being used in all program materials. Nominee Name (please print) Signature Date Parent/Guardian if under 18 Signature Date (please print) On behalf of which group (if applicable):

7 Step 7 Completed Nominations Please ensure that you have included all the following information: Step 1: Information on the individual/group being nominated Step 2: Reason for the Nomination Step 3: Support Letters for the Nomination #1 #2 Step 4: Additional Documentation (pictures required) Step 5: Information about you, the Nominator Step 6: Declaration Nominator Nominee All completed nominations must be submitted on or before September 30, 2017, by 12:00 p.m. For more information or to drop off completed nominations, please contact: Regional Municipality of Wood Buffalo Attn: Community Strategies 9909 Franklin Avenue Fort McMurray, T9H 2K4 champions@rmwb.ca Phone: