Al Felmet Achievement Award - Cerebral Palsy Associations of New York State

Al Felmet Achievement Award Nomination Form

Please fill in the form below and submit when complete.

Should you require a PDF of this form to fill out manually, please contact Kelsey Massyk at kmassyk@cpstate.blackdogsitetesting.com to request a downloadable copy.

Purpose

Recognizes a person with cerebral palsy whose achievements are an inspiration to others.

Eligibility

Any person with cerebral palsy who is at least 16 years of age, who has made a significant contribution to society, and is regarded as an inspiration to people of all abilities.

Nominee Information

Name of Nominee(Required)

Prefix First Last

Nominee Email Address(Required)

Nominee Phone #(Required)

Contact Person Full Name(Required)

Contact Person Email(Required)

Contact Person Phone #(Required)

What contributions has this person made?(Required)

How have these contributions been an inspiration to others?(Required)

Please upload two (2) letters of endorsement from Affiliate staff members or volunteers.

Drop files here or

Max. file size: 128 MB.

Please upload any other appropriate supporting documents.

Drop files here or

Max. file size: 128 MB.

Please upload a photo or photos of the nominee.

Drop files here or

Max. file size: 128 MB.

Nominating Party Information

Nominating Party Name(Required)

First Last

Job Title(Required)

Agency(Required)

Email(Required)

Phone(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code