Athletes with Disabilities Hall of Fame
2007 Official Nomination Form
The official nomination form should be used to nominate an individual for consideration for any category listed above. Please note the detailed description of each award and the nominating criteria outlined in the official nomination instruction booklet. Please complete this form in its entirety. To be considered, the official nomination form should be accompanied by a current photo of the nominee, a detailed summary of their athletic and community involvement, and a minimum of two letters of recommendation. Attach additional sheets, as necessary. We also encourage supporting documentation about the nominee such as media coverage, articles, certificates, athletic photographs, etc. |
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NAME OF NOMINEE:
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____________________________ | PHONE: (____)_____-______ |
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STREET ADDRESS:
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____________________________ | EMAIL: __________________ |
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CITY:
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____________________________ |
STATE: ______ ZIP: _______ |
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DATE OF BIRTH:
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_____________ GENDER:
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FEMALE MALE
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HOMETOWN:
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_____________ PLACE
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OF BIRTH:______________
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TYPE OF DISABILITY:
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Spinal Cord | Visually Impaired |
| Muscular Dystrophy | Developmentally Disabled | |
| Mentally Challenged | Dwarf | |
| Hearing Impaired | TBI | |
| Amputee | Cerebral Palsy | |
| Multiple Sclerosis | ||
| Other (please specify):_______________________________ | ||
| SPORT(S) IN WHICH THE NOMINEE PARTICIPATES/PARTICIPATED: ___________________________________________________________________________ ___________________________________________________________________________ |
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| SPECIFIC ATHLETIC EVENTS IN WHICH THE NOMINEE COMPETED: Year Name of Competition Sport/Event Result ____ ________________________________ ______________________ __________ ____ ________________________________ ______________________ __________ ____ ________________________________ ______________________ __________ ____ ________________________________ ______________________ __________ ____ ________________________________ ______________________ __________ ____ ________________________________ ______________________ __________ ____ ________________________________ ______________________ __________ |
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| LIST AWARDS, HONORS, RECORDS, AND OTHER SPECIAL ATHLETIC ACHIEVEMENTS: (attach additional sheets if more space is required) Year___ Recognition ______ __________________________________________________________________ ______ __________________________________________________________________ ______ __________________________________________________________________ ______ __________________________________________________________________ ______ __________________________________________________________________ ______ __________________________________________________________________ |
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| HISTORY OF COMMUNITY INVOLVEMENT AND/OR PROFILE AS A POSITIVE ROLE MODEL: (attach additional sheets if more space is required) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ |
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| OTHER NOTES OF INTEREST ABOUT THE NOMINEE: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ |
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We encourage supporting documentation about the nominee such as letters of recommendation, media coverage, articles, certificates, photographs, etc. The nominating committee will be contacting you between 5/01/07 and 5/31/07 to verify the enclosed information. Thank you for your support of the Athletes with Disabilities Hall of Fame.
| Name of Individual Submitting Nomination: __________________________________
Name of Organization (if applicable): ________________________________________ Street Address: ___________________________________________________________ City: _____________________________ State: ______________ Zip Code: ________ Day Phone: ________________________ Evening PHone: ______________________ Email: ___________________________________________________________________ Signature: ____________________________________ Date: ____/____/_______ |
The completed nomination package including the official nomination form and any supporting materials must be received by:
Friday, June 1, 2007 at 5:00 p.m. ET via U.S. mail or in-person delivery.
Please return to:
Athletes with Disabilities Hall of Fame, Attn: Nominations,
2845 Crooks Rd., Rochester Hills, MI 48309
For more information, contact us at (248) 829-8353 or info@adhof.org
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