ASEA AWARD NOMINATION FORM
Please send your nominations to autism@autismedmonton.org
or mail to - 101, 11720 Kingsway Ave, Edmonton AB T5G 0X5
Deadline for nominations is February 16th, 2015
Name of Nominator:
Mailing Address:
Phone Number:
E-mail address:
Relationship to Nominee: (e.g. name of individual with autism, settings/locations, brief
history of relationship)
Name of Nominee:
Mailing Address:
Phone Number:
E-mail address:
Nominee’s Agency/School/Place of Employment:
Nominee’s Supervisor/School Principal:
Categories of Awards for Nominee (Check only ONE per nominee):
NOTE: Please see Appendix A for the explanation/eligibility for each category of award.
Category A: Workplace Champion(s)
 Supervisor/Manager(s)
 Work Team  Workplace
Category B: Business Champion
 Business Champion
Category C: Educational Champion(s)
 Teacher(s)
 Teaching Assistant(s) Administrator(s)
Category D: Autism Service Champion(s)
 Support Worker(s)
 Therapist(s)  Organization/Program Leader(s)
 Other, please specify: ___________________________________
Category E: Community Champion(s)
 Community Champion(s)
Category F: Student Champion(s)
 Elementary Student(s)
 University/College Student(s)
 Junior High Student(s)
 High School Student(s)
PLEASE FEEL FREE TO USE ADDITIONAL PAGES TO ANSWER THE FOLLOWING QUESTIONS:
What association does the nominee have with individuals on the Autism spectrum?
What are the special characteristics and/or contributions of this nominee that would make
him/her/organization a deserving award winner in the field of Autism?
 FOR EXAMPLE:
o Has the nominee improved the lives of individuals on the autism spectrum OR
o Created a place of employment that enables employees with autism to excel OR
o Created a learning environment that enables students with autism to thrive OR
o Significantly increased awareness, acceptance, and/or support for the cause of autism OR
o Made other significant contributions to the field of Autism, AND
o If yes, how so?
How have the actions of the nominee changed the lives of individual(s) with autism?
Nominator’s signature: _________________________________________________________
Date: ________________________________________________________________________
APPENDIX A: Explanation/Eligibility for Each Category of Award
Category A: Workplace Champion(s)
This category is awarded to an individual manager, a team, or an organization that has contributed to the
work success of employees with autism, either through innovative work practices, creative accommodation,
excellent management and/or other applications.
Category B: Business Champion
This category is awarded to a business entity that demonstrates interest, care, and support for individuals with
autism, either through the provision of innovative need-fulfilling products and services to individuals with
autism, provision of significant resources/aids to autism-related projects or causes, and/or other special
provisions. (Note: Specialized Autism Service Providers are not eligible for this award. Please refer to
Category D)
Category C: Educational Champion(s)
This category is awarded to an individual or a team of teachers, teaching assistants, and school
administrators that have gone the extra mile to create a learning environment where children with autism
could thrive, learn, and develop at their highest potential.
Category D: Autism Service Champion(s)
This category is awarded to an individual or a team of support workers, therapists, organization/program leaders
or other working members of an Autism Service Provider agency, government department, or community entity
that have provided outstanding service to their clients with autism.
Category E: Community Champion(s)
This category is awarded to an individual or a team of individuals that have acted as outstanding champions for
the cause of autism, either through their effective and significant advocacy efforts, significant voluntary work with
the autism community, creation and/or leadership in events, projects, ventures, or activities that significantly
benefited individuals with autism or their families, and/or leadership in other initiatives that significantly benefited
individuals with autism.
Category F: Student Champion(s)
This category is awarded to an individual or a team of students in elementary, junior high, high school or
college/university that have demonstrated leadership in making a positive difference in the field of autism by
initiating and leading an activity, event, project, venture, or advocacy effort to generate resources/aid/support for
their fellow students with autism or for the cause of autism as a whole, or by leading other meaningful initiatives.