Nominations will be accepted no later than September 1^st of each year, and must be submitted through this form. Dementia Care Professionals of America may request supplemental materials, such as photographs or additional testimonials. All nominations for the same professional must be submitted separately.

Nominator Information

* Name:

* Home Address:

* City:

* State:

* Zip Code:

* Home Phone:
use (xxx-xxx-xxxx) format

Cell Phone:

* Email address:

(If Applicable)

Title:

Employer:

Business Address:

City:

State:

Zip Code:

Business Phone:
use (xxx-xxx-xxxx) format

Business Email Address:

Nominee Information

* Name:

* Title:

* Employer:

Business Address:

* City:

* State:

* Zip Code:

* Business Phone:
use (xxx-xxx-xxxx) format

* Business Email Address:

Home Address:

City:

State:

Zip Code:

* Home Phone:
use (xxx-xxx-xxxx) format

* Cell Phone:

Questionnaire

* How long have you known the nominee?

* What is your relationship to the nominee? List all that apply (e.g. “The nominee is my supervisor, mentor and sister-in-law).

* What are the credentials, licenses, educational achievements of the nominee?

* What is the nominee’s career history?

* In what capacity, and for how long, has the nominee provided service to individuals with dementia and their families?

* Which of the following describes the reason(s) for this nomination? Check all that apply.

Achievements through overall career of service

Changes to the care system or field of practice

Development of successful models of care and intervention

Positive impact on colleagues or workplace

Positive impact on families

Extraordinary service to clients

Other

* In your own words, describe the reason(s) for this nomination. Include specific examples of the nominee’s accomplishments, successes and impact on the client, community or field of practice, or career achievements. (Maximum 1,000 words)

*AFA and DCPA may use information provided on the nomination form for publicity purposes. The award winner must agree to submit a photograph for publicity purposes and to be available for interviews with the media.

* Indicates Response Required