Anthony J. Koenig Volunteer Service Award - Cerebral Palsy Associations of New York State

Anthony J. Koenig Volunteer Service 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 someone who has volunteered significant time and energy to people with disabilities and/or initiated local community action and support which has enhanced the lives of people with disabilities.

Eligibility

Any volunteer from an Affiliate at the local or state level or any individual representing school districts, civic groups, churches, the media, business or other local community groups. The volunteer must have been working with Cerebral Palsy Associations of New York State Affiliates for the full calendar year prior to the time of the nomination.

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)

Length of Service as a CP Volunteer:(Required)

What contributions has this person made to his or her CP Affiliate and the individuals who receive services?(Required)

Please describe how the contributions have enhanced the lives of people with disabilities and/or generated positive community support for CP of NYS, an Affiliate, its programs, or the people served:(Required)

What activities has the nominee undertaken to enhance the lives of people with disabilities?(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.

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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 Number(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code