NH Family Leadership Award 2012 Nomination Form

							                                     BRIANNA ROSE DILLON

                          NH FAMILY LEADERSHIP AWARD - 2012



        This NH Family Leadership Award was established in 2011 in honor of Brianna Rose Dillon by her
family. Brie benefited greatly from the work of so many NH families, professionals, agencies, and
organizations to help her achieve a rich and happy life. This award will be given at the NH Family Support
Conference on May 5-6, 2012, a conference Brie enjoyed for many years, and a cherished forum for NH
Families that offers a place to gather, grow, learn, and celebrate together.

        The Award will be given to a NH FAMILY (of a person who has a disability) who has contributed to
their community and state to promote inclusion of people who have disabilities, to work toward
improving systems of support, and who has inspired, advocated, and led with a strong vision of full
community participation, assuring full and meaningful lives for all people who have disabilities.

   To Nominate a family who meets this criteria please:

   1. Print out the back side of this form.
   2. List several (two or more) family names who have engaged in leadership activities.
   3. Fill in your contact information.
   4. Enclose a typed/written description of details describing actions of each of several family
      members (two or more) who have worked to:
            Support individuals who have disabilities to have rich, meaningful, and inclusive lives
            Build and strengthen community
            Volunteer on behalf of families/individuals who have disabilities
            Advocate for improvement of services and systems
            Contribute to family support efforts statewide
            Provide leadership and inspiration to others
            Work throughout NH (and beyond)
   5. By April 1, 2012,
          Mail to: The Dillon’s, 7 Wendell Drive, Brentwood, NH 03833
           OR
           Scan and send to dill5@comcast.net
   6. A panel consisting of NH family members and others will select the award recipient. The family
      will be notified by mid April.


                                                  OVER
Fill this out and attach your narrative description.

               Family Names                                    Nominator
1)                                             Name:

2)                                             Address:

(etc.)

                                               Town, State, Zip:

One Address:
                                               Phone Number:

Town, State, Zip:
                                               Email:

Phone Number:

Email:




Thank you very much for your nomination!
Don’t forget to attach your narrative of why this family should be nominated.
Please make sure your nomination is received by April 1, 2012.

Mail to: The Dillon’s, 7 Wendell Drive, Brentwood, NH 03833
                      OR
Scan and email to dill5@comcast.net