2008 Mowrer Self-Help/Support Group
Award Form
Please return this form by Friday, September 5th,
2008 to: The Self-Help Center of Family Service
405 S. State St., Champaign, IL 61820
Please check nomination category below. Use a separate form for each nomination you
submit.
Group Award -
___New
Self-Help/Support Group
___Individual Award -Layperson Group Leader
(in existence at the local level 1-2 years)
Group Award -
___Established
Self-Help/Support Group ___Individual Award - Professional Support Person
(in existence at the local level 3+ years)
Nominator
Name:__________________________ Daytime
Phone # or e-mail:___________________________________
Nominee Name
:___________________________ Daytime
Phone # or e-mail:___________________________________
(You may use first name only if
preferable.)
Address of
Nominee:___________________________________________________________________________________________
Name of Self-Help/Support
Group:_____________________________________________________________________________________________
1.
List the nominee’s (individual/group) most important achievements
in the area of self-help/mutual aid.
Include in the description what the individual or group has accomplished
that makes it important, innovative or stand out as exceptional in its service
to the group or the community at large.
2.
How has this individual or group impacted people’s
lives either within the group or in the larger community?
3.
List any or unusual challenges which the
individual/group had to surmount to be successful.
Please feel free to submit newspaper clippings,
newsletter, or other items of interest with this application form. You may add one additional page for response
to questions above. Do not submit
videotapes. Nomination forms and other
items submitted will not be returned