Nancy Burgess-Hall Award Nomination Form

Application Deadline is July 15, 2023

Nominee Information

First Name

Last Name

Phone

Address Line 1

Address Line 2

City

State

Postal Code

Gender Pronouns

Primary Language

Is the nominee 18 years old or younger?

YesNo

Applicant Profile

Please tell us a bit about the nominee and their commitment to protecting and advancing the rights of people with disabilities through civic engagement in 500 words or less. For example, how do their efforts demonstrate inclusiveness, dedication and a spirit of cross- collaboration?

References

Name

Phone

Name

Phone

Optional Supporting Documentation

If you wish to upload one or more documents, use the Choose File buttons below. You can upload up to five documents here.

Supporting documents can alternatively be emailed to lauram@disabilityrightsflorida.org

Contact Information