Community Champions

Nomination Form

Deadline for entries is Friday, February 27, 2009.

Please limit your nomination to 300 words. All parts of your nomination must be complete for judges to review.

Your description should be as specific as possible. Please include:

  • The name of the organization for which your nominee volunteers.
  • The number of hours your nominee volunteers each month.
  • A description of how his or her efforts benefit the community.
  • A short story that demonstrates the character and qualities of the individual and his or her volunteer efforts.

I nominate the following as a Community Champion/Jefferson Award Nominee:

Name

Address

City, State, Zip

Telephone (daytime)

Telephone (evening)

Age Range

Contact to verify the accuracy of the nomination information:

Non-profit organization

Name of contact person

Name of Executive Director

Address

City, State, Zip

Website address

Telephone

Please complete the following about yourself:

Name

Address

City, State, Zip

Telephone (daytime)

Telephone (evening)

Email

Relation to nominee

How did you hear about this program:
 post-gazette.com Brochure mailing Post-Gazette Ad United Way Other