2016 BuckleUpNC Conference

May 4-6, 2016 | Raleigh, North Carolina

Child Passenger Safety Save
Award Nomination Form

The North Carolina Child Passenger Safety Conference Committee recognizes Child Passenger Safety Technicians or Programs that have, through actions related to CPS Programs and/or events, contributed to saving the life of a child involved in a crash.

Use this nomination form to recognize known/documented CPS saves. Documentation can include data from program related materials, letters and/or statements from individuals who were involved in the collision and/or save. All individuals and/or programs nominated for this category will be recognized.


Application Submitted By (Self-nomination is permitted):

Name:
Organization/Agency:
Phone: / ()
Email:

Will you be able to provide a digital image of the nominee for use at the BuckleUpNC Conference Award Ceremony? (Having a photo is not required for the nominee to win, but one will be needed prior to the Conference for winners.)

Yes No

Nominee/Program Information:

Nominee/Program Name:
Organization/Agency:
Phone: / ()
Email:

The following form will be reviewed by the BuckleUpNCAwards Committee. Please be as detailed as possible.

All Saves will be recognized during the 2016 NC BuckleUpNC Conference.

SUBMISSIONS MUST BE RECEIVED BY 5:00PM, FRIDAY MARCH 11, 2016 for recognition at the 2016 BuckleUpNC Conference. Forms submitted after this deadline will be accepted and recognized at the 2017 conference.

Submit nominations by email to:

SUBJECT:CPS Awards - Save

E-MAIL:

1. Briefly describe the circumstances of the crash.

2. Briefly describe the child’s age and if known, the seat he/she was riding in.

3. How did the nominee contribute to the “save?”

SUBMISSIONS MUST BE RECEIVED BY 5:00PM, FRIDAY MARCH 11, 2016 for recognition at the 2016 BuckleUpNC Conference. Forms submitted after this deadline will be accepted and recognized at the 2017 conference.

Submit nominations by email to:

SUBJECT:CPS Awards - Save

E-MAIL:

Copies of this application can be downloaded from: January 25, 2016