2013 NOMINATION FORM (July 11, 2012) CATEGORY (Check one only) The Arts: The Jacqui Shumiatcher Arts Award Leadership and Management Community Leadership and Enhancement Lifetime Achievement Contribution to a Rural Community Science, Technology and Environment Cultural Heritage Circle of Friends Education and Mentorship Wellness, Recreation and Healthy Living Entrepreneurship and Innovation Young Woman of Promise NOMINEE (please print clearly if filling form out by hand) TITLE: Miss Ms. Mrs. Dr. Other (please specify) _____________________ PREFERRED GIVEN NAME: (what does the nominee like to be called in conversation?) _______________________________ SURNAME: _________________________________________ DATE OF BIRTH:_________________________ SPELL NAME PHONETICALLY (for pronunciation): __________________________________________________ ADDRESS: __________________________________________________________________________________ _______________________________________________________________________________________________ CITY: ____________________________________ POSTAL CODE: _______________________________________ BUSINESS PHONE: ________________________ HOME PHONE: _______________________________________ E-MAIL: __________________________________ FAX: ________________________________________________ ATTESTATION & SIGNATURE I, ______________________________________ (Nominee’s name—please print clearly if filling out form by hand ) declare that the information contained in this Nomination Package is true to the best of my knowledge. I also consent to my nomination for the 2013 Regina YWCA Women of Distinction Awards. I will allow my name and photo to be published in connection with the awards program, and will make an effort to attend the Women of Distinction Reception on Saturday, April 13, and the Awards Gala on Thursday, May 2, 2013, at the Conexus Arts Centre. Nominee’s signature: ____________________________________________ Date: ____________________________ OPTIONAL: The Leader Post may contact your employer to invite them to participate in a special advertising feature. Employer: ____________________________________________ Contact name: ______________________________ * Each nominee will receive two free Reception tickets and one complimentary Gala ticket. NOMINATOR (please print clearly if filling form out by hand) NAME: (Group) _________________________________________________________________________________ NAME: (Individual)_______________________________________________________________________________ (If this nomination is being submitted by a group, please indicate the team/group name, the names of the individuals in the group—in whatever order is appropriate—plus the name of your representative who may be contacted if necessary.) ADDRESS: _____________________________________________________________________________________ _______________________________________________________________________________________________ CITY: _____________________ PROV.: ________________ POSTAL CODE: ______________________________ BUS. PHONE: ___________________________________________________________________________________ RES. PHONE: ___________________________________________________________________________________ E-MAIL: _______________________________________________________________________________________ FAX: __________________________________________________________________________________________ ATTESTATION & SIGNATURE I hereby declare that the information contained in this Nomination Package is true to the best of my knowledge. Nominator’s signature: _____________________________________________________________________ Date: ________________________________________ • All nominations and deliberations of the Nominations and Selections Committee will be treated confidentially. • The decisions of the Selections Committee are final. NOMINEE QUALIFICATIONS • The Nominee must be a woman (or group OF TWO OR • A woman may be nominated in only one category each MORE WOMEN, WHO MUST BE PLACED IN THE year. Past Award recipients may be re-nominated in other “CIRCLE OF FRIENDS” CATEGORY) living in southern years for a category in which they did not receive an award. Saskatchewan at the time of nomination. “Southern Unsuccessful nominees may be re-nominated in subsequent Saskatchewan” is considered to be roughly south of a line years in the same or different category. running east and west through Davidson. If you’re unsure of • To avoid conflict of interest, neither the Nominee nor the your Nominee’s residential qualification, please contact the Nominator may be a member of the Women of Distinction co-ordinator at 525-2141. Committee, the Women of Distinction Nomination or • Posthumous nominations WILL NOT be accepted. Selections Committee, Regina YWCA Board of Directors or • Award categories may be changed, added or eliminated at Regina YWCA staff. the discretion of the Committee and the YWCA. • In the event of an unexpected number of nominations, the • From time to time, at the discretion of the YWCA and the committee reserves the right to limit short-listed candidates Women of Distinction Awards Committee, special awards in any award category. may be presented to honour women who are alive or deceased. NOMINATION CRITERIA 1. The Selection Committee will make their decisions based on the criteria listed below. Please write a profile of your nominee, including 1-4 paragraphs addressing each of the seven criteria. Highlight how your nominee has achieved outstanding success by: Being a leader and role model in the community Breaking new ground, eliminating barriers or being an agent for change Participating actively as a volunteer Guiding, supporting and encouraging the development of others in the community Showing vision, creativity and initiative Achieving unique and outstanding accomplishments within and/or outside of the nomination category Enriching the community and impacting others 2. From your heart, why do you think this person should receive an award? From a personal perspective, why are you nominating this person? 3. Please provide a brief biography (around 150 words) including the most important facts and accomplishment from the nominee’s life. This material will be incorporated into the information prepared for the Reception and Gala programs and other Awards materials. To the best of our ability, all biographies will be submitted for approval to the Nominee or Nominator prior to use. REFERENCES Please include one to three (1 – 3) letters of reference in support of your nominee. Please ensure that contact information is included, and that the references are aware that they may be contacted.