Program Innovation 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

To recognize an Affiliate of CP State that has provided an exemplary program to people with disabilities that has enhanced the independence and self-esteem of its participants and which serves as a model to be replicated across New York State.

Eligibility

Any Affiliate of CP State which develops and operates programs for people with disabilities and their families.

Nominee Information

Name of Nominee(Required)
We recognize that there are usually several people who contribute to the creation of a program, so please use who would be considered the "leader" of this effort, if possible. Please keep in mind that only one person may give a brief speech upon receiving the award on stage, but we allow more than one person to come on stage, so other contributors can still be present at that time. (There is a space to add those names below, if desired.)
Feel free to list those who also greatly contributed to the conception of the nominated program. Please keep in mind that while we allow more than one person on stage to accept the Program Innovation Award, only one can give a speech.
Drop files here or
Max. file size: 128 MB.
    Drop files here or
    Max. file size: 128 MB.
      Drop files here or
      Max. file size: 128 MB.

        Nominating Party Information

        Nominating Party Name(Required)
        Mailing Address(Required)
        Attestation(Required)