Valuing Mental Health Excellence in the NAMI Central Virginia Community

Nomination Form

How to nominate

Anyone may submit a nomination. Incomplete forms may be considered ineligible for assessment.

Mail, email, or fax your completed form to:

NAMI Central Virginia
Attn: Kathy Harkey
1904 Byrd Avenue, Suite 207
Richmond, VA 23230
Phone: (804) 285-1749
Fax: (804) 285-0069
Email:

Applications close

April 11, 2017 (To learn more about the award categories visit www.namicentralvirginia.org)

Award Categories: Distinguished Community Partner Award; CIT Officer of the Year Award; NAMI-CVA Members Choice Award; NAMI-CVA Mental Health Services Award; NAMI-CVA Outstanding Contributions Award; NAMI-CVA Volunteer Champion Recognition Award. Award Recipients will be recognized on April 20th at the 2017 NAMI-CVA Awards Banquet.

Which Award are you nominating this individual/group for? ______

Nominee Details:

First name: / Last name:
Nominee’s postal address:
(This information is not required but preferred)
Nominee’s phone number:
Nominee’s email address:
Is the individual affiliated with NAMI-CVA (directly or indirectly):
Nominee’s length of time serving people affected by mental illness (i.e. number of years, or number of months):
In what capacity does he/she assist people living with mental illness and their families:


Award criteria

When making your nomination, please provide short statements describing how the nominee meets the following award criteria. Where possible, provide examples to support the statements. (Please use additional sheets if necessary)

1.  Demonstrated benefit to the mental health community.

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2.  Demonstrated achievements of the nominee and the work for which he/she is being nominated.

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3.  Demonstrated qualities (attitude, support provided) in their role.

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4.  Demonstrated evidence of innovation or obstacles which the nominee may have had to overcome (if any) to assist people with mental illness and their families.

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Nominated by

Name:
Organization:
Address:
(not required
but preferred)
Telephone:
Email:
Signature and Date: