Community Leader Award

Hamilton Relay recognizes an individual in each Hamilton Relay contracted state who is Deaf, DeafBlind, hard of hearing, late-deafened or who has difficulty speaking and demonstrates strong leadership and volunteerism within the community. Additionally, an individual or organization that demonstrates leadership and volunteerism in the Deaf, DeafBlind, hard of hearing or speech difference community may be nominated for this award.

Or you can download the MS Word document or download the PDF and submit the completed form to your State’s Outreach Coordinator or directly to Hamilton Relay’s corporate office:
Email: info@hamiltonrelay.com
Fax: 402-694-5110
Mail: Hamilton Relay, 1006 12th Street, Aurora, NE 68818.

For more information, contact your state outreach coordinator

Nominee/Organization Information:

Name of Nominee/Organization*

Nominee/Organization’s Address

Address (Line 1)

Address (Line 2)

City

State

Zipcode

Phone Number

Please check one

Voice

TTY

CapTel

VP

Phone Type Other

Other

Please Specify Other

Email Address

The Nominee

is Deaf

is hard of hearing

is late-deafened

has difficult speaking

is hearing

is an organization

n/a

Nominee Qualifications:

How has the nominee been active and/or made an impact in the community? Please focus primarily on providing information pertaining to the volunteer efforts and accomplishments completed beyond regular job duties.*

List the names of associations, organizations, clubs or other activities in which your nominee has been involved. Include position(s) held, term length and any other pertinent details. If nominating an organization, list work and accomplishments that have made an impact the Deaf, hard of hearing, DeafBlind and/or speech difference communities.*

What are the strongest points about the nominee?*

Please feel free to include additional information as needed.

References:

Please list two references (other than yourself) and their contact information.

Reference #1*

Name*

First Name

Last Name

Phone Number*

Email Address*

Reference #2*

Name*

First Name

Last Name

Phone Number*

Email Address*

Your Information:

Please include your contact information.

Your Name*

First Name

Last Name

Phone Number*

Email Address*

Submit Nomination

* Required information

Community Leader Award

To nominate someone in your state, complete the form below.

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