Notice of Meeting of the Board of Directors

							                            Making A Difference Award
                                Nomination Form
           “Making A Difference in the Multiple-Birth Community”
                                    (Confidential when completed)



DIONNE AWARD

   Presented annually to ADULT multiple-birth individual(s) who through his/her/their actions
   have created a deeper awareness of the challenges faced by Canada’s multiple-birth children
   and their families and/or have made a significant impact on the multiple-birth community
   through their own personal efforts.


Nominee Information:
   Full Name:
   Home Address:
   Email Address:
   Telephone:


Nominator Information:
   Full Name:
   Home Address:
   Email Address:
   Telephone:


Reference Information: (please supply one contact person that can confirm information supplied)
   Full Name:
   Home Address:
   Email Address:
   Telephone:




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office@multiplebirthscanada.org                             www.multiplebirthscanada.org
Please provide the following information in as much detail as possible.

Reasons why you are nominating this individual or these individuals; include positions the nominee(s)
has/have held in organizations, and the dates of active participation in such organizations, through which
he/she/they demonstrated an ability to increase awareness of the challenges facing multiples (if
applicable); any official honours or awards received; and any other information which will help the MBC
Board of Directors to make an informed decision for this award.



This form, and the information contained therein, is confidential. I confirm the above information is valid
and true to the best of my knowledge and that the nominee has been advised of this nomination. Please
sign below if you consent to the MBC Board of Directors, releasing your comments to the nominee upon
request.


Nominator’s Signature:                  Date:
   select box if agreeing to sign and send electronically in lieu of handwritten signature

  Note: A picture of the nominee is requested to be sent at the time of nomination submission or shortly thereafter.


                                       Send nomination form via mail or email to:
                                       Making a Difference Awards Chairperson
                                        Box 9 RR #4, Rockwood, ON N0B 2K0
                                Email: makingadifference@multiplebirthscanada.org




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office@multiplebirthscanada.org                                               www.multiplebirthscanada.org