Pam Henry Media Award Nomination Form

Please give us your contact information.

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

Your Email (required)

Please provide the nominee's name, address, phone number and email address:

Name of Nominee:
Address of Nominee:

Telephone Number of Nominee:
Nominee's Email

Please include a copy or link to the media story that this individual or group produced.

Please name the media outlet, group, or agency where the individual you are nominating works. Include the division or work location of the individual if known.

Please describe how this media piece promotes individuals with disabilities in an empowering and positive manner (please be specific).