George Lewis Award Nomination Form

Please give us your contact information.

Your Name (required)
Your Phone (required)
Your Address

Your Email (required)

Please complete all the information below. Incomplete nomination forms will not be considered for an award.

Who are you nominating for this award:
Address of Nominee:

Telephone Number of Nominee:
Nominee's Email

Please describe the current occupation of the individual you are nominating and explain how this employment empowers and encourages others with disabilities. Please be as detailed as possible.

Please describe activities this individual is involved in that enhance the empowerment of individuals with disabilities (please include specific examples and list the level of impact those activities have had including number of individuals, programs, or activities helped by these activities).

Please describe this individual’s community involvement (please include full organization names and provide specific examples of involvement and the level of impact those activities have had).

Please describe how this individual has risen above his/her disability.

Please describe community activities this individual has promoted or participated in that aid others in overcoming barriers and improving accessibility.