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2010 Parent Leadership Conference NOMINATION FORM FOR PARENT

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					NOMINATION FORM FOR PARENT During the 2010 Parent Leadership Conference, we plan to honor two (2) parents who have gone that “extra-mile” to support and partner with families, participate on planning committees, assist with program development, and/or who have contributed to a special project that changed the course of a family’s life or has made a difference in their community. For example, excellent leadership practices may be demonstrated through:       Support and partnering with parents Involvement in planning of local community or state projects or services Representation on Parent Advisory Councils, committees and community activities related to child welfare services and other systems such as early childhood development, mental health, juvenile justice, etc. Training/coaching other parents to be Parent Leaders Involvement in evaluating programs or services Working effectively with agency staff on organizational issues to strengthen services for families.

Nominee Information Name of Parent Title of Parent Agency Address City Telephone Nominator Information Name Title Agency Address City Telephone

State Email

Zip

State Email

Zip

Two References Required (One from a Parent and One from a Staff Member) Name of Parent Agency Address City State Zip Telephone Email Name of Staff Member Agency Address City Telephone

State Email

Zip

Please answer the following questions about the Parent nominee:

1. Please describe some of the leadership roles in which this nominee has been involved.

2. Please describe how this nominee has supported and partnered with other parents and families.

3. Please describe how this nominee has been involved with committees, task forces or other special projects that have made a difference with families and or communities.

4. Please provide any other information that you feel would be helpful.

This completed form must be received by Parents Anonymous® Inc. either by mail, fax or email, by December 18, 2009. Send to: Parents Anonymous® Inc. Attn. Meryl Levine, Vice President of Development 675 W. Foothill Blvd., Suite 220 Claremont, CA 91711 mlevine@parentsanonymous.org Fax: (909) 575-4224


				
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Description: 2010 Parent Leadership Conference NOMINATION FORM FOR PARENT Send to: Parents Anonymous® Inc. Attn. Meryl Levine, Vice President of Development 675 W. Foothill Blvd., Suite 220 Claremont, CA 91711 mlevine@parentsanonymous.org Fax: (909) 575-4224