SOUTHEASTERN ASSOCIATION OF AREA AGENCIES ON AGING
2015 JANE KENNEDY EXCELLENCE IN AGING AWARD
NOMINATION FORM
Nominee’s Full Name: _____________________________________________________________
Address: _________________________________________________________________________
City/State/Zip Code: _______________________________________________________________
Phone Number: _____________________________ Present Age: ___________________________
Occupation: ______________________________________________________________________
Place of Work: ____________________________________________________________________
Address: _________________________________________________________________________
City/State/Zip Code: _______________________________________________________________
Education: _______________________________________________________________________
Degrees: _________________________________________________________________________
Academic Honors, etc. ______________________________________________________________
Organizations: ____________________________________________________________________
Elderly Advocacy Efforts: ___________________________________________________________
NARRATIVE ON NOMINEE (Include reasons person merits the Award.):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Will the nominee attend the SE4A Conference? Yes ______
No ______
(Additional sheets may be used. Limit is three pages; double space, 12 point font. Be sure to attach
them to the Nomination Form before submission for judging.)
Name of Sponsoring AAA: ________________________________________________________
Contact Person: __________________________________________________________________
Address: ________________________________________________________________________
City/State/Zip Code: ______________________________________________________________
E-Mail Address:__________________________________________________________________
(Note: Sponsoring AAA will be responsible for facilitating notification & luncheon attendance of award recipient)
Please return this form no later than June 8, 2014 to Barbara Gordon, Awards Chair.
Barbara Gordon, Director
KIPDA AAAIL/ADRC
11520 Commonwealth Dr.
Louisville, KY 40299
barbara.gordon@ky.gov
SOUTHEASTERN ASSOCIATION OF AREA AGENCIES ON AGING
2015 POSITIVE IMAGES IN AGING AWARD
NOMINATION FORM
The POSITIVE IMAGES OF AGING Award was established by the Southeastern Association of
Area Agencies on Aging to recognize groups, agencies, or businesses in the private and/or public
sector who have, through their efforts, presented a positive image of older adults or individuals
whose platform has impacted a large market.
Nominee’s Full Name/Title: _________________________________________________________
Address: _________________________________________________________________________
City/State/Zip Code: _______________________________________________________________
Phone Number: _____________________________ Fax Number: ___________________________
NARRATIVE ON NOMINEE, including reasons this group, agency or business merits the award.
(Use extra pages as necessary. Limit is three pages; double space, 12 point font. Any visual aids
would be appreciated.)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________
Will a representative for the nominee attend the SE4A Conference? Yes ______ No ______
Name of Sponsoring AAA: ________________________________________________________
Contact Person: __________________________________________________________________
Address: ________________________________________________________________________
City/State/Zip Code: ______________________________________________________________
Phone Number: ____________________________ Fax Number: ___________________________
E-Mail Address: __________________________________________________________________
(Note: Sponsoring AAA will be responsible for facilitating notification& luncheon attendance of award recipient.)
Please return this form no later than June 8, 2015 to Barbara Gordon, Awards Chair.
Barbara Gordon, Director
KIPDA AAAIL/ADRC
11520 Commonwealth Dr.
Louisville, KY 40299
OR
barbara.gordon@ky.gov
SOUTHEASTERN ASSOCIATION OF AREA AGENCIES ON AGING
2015 CORPORATE PARTNERSHIP AWARD
NOMINATION FORM
(Public Agency)Nominee’s Full Name/Title: __________________________________________
Address: _________________________________________________________________________
City/State/Zip Code: _______________________________________________________________
Phone Number: _____________________________ Fax Number: ___________________________
(Private Agency)Nominee’s Full Name/Title: __________________________________________
Address: _________________________________________________________________________
City/State/Zip Code: _______________________________________________________________
Phone Number: _____________________________ Fax Number: ___________________________
NARRATIVE ON NOMINEE, including reasons these organizations merits the Award. (Use extra
pages as necessary. Limit is three pages; double space, 12 point font.)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Will a representative for the nominee attend the SE4A Conference? Yes ______ No ______
Name of Sponsoring AAA: ________________________________________________________
Contact Person: __________________________________________________________________
Address: ________________________________________________________________________
City/State/Zip Code: ______________________________________________________________
Phone Number: ____________________________ Fax Number: ___________________________
E-Mail Address: ________________________________________________________________
(Note: Sponsoring AAA will be responsible for facilitating notification & luncheon attendance of recipient)
Please return this form no later than June 8, 2015 to Barbara Gordon, Awards Chair.
Barbara Gordon, Director
KIPDA AAAIL/ADRC
11520 Commonwealth Dr.
Louisville, KY 40299
OR
barbara.gordon@ky.gov
SOUTHEASTERN ASSOCIATION OF AREA AGENCIES ON AGING
2015 OUTSTANDING COMMUNITY SERVICE AWARD
NOMINATION FORM
The OUTSTANDING COMMUNITY SERVICE Award was established by the Southeastern
Association of Area Agencies on Aging to recognize religious institutions, service agencies and
organizations, civic clubs, and governmental departments that have made positive contributions to
the lives of older people.
Nominee’s Full Name/Title: _________________________________________________________
Address: _________________________________________________________________________
City/State/Zip Code: _______________________________________________________________
Phone Number: _____________________________ Fax Number: ___________________________
NARRATIVE ON NOMINEE, including reasons this group, agency or business merits the award.
(Use extra pages as necessary. Any visual aids would be appreciated.)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________
Will a representative for the nominee attend the SE4A Conference? Yes ______ No ______
Name of Sponsoring AAA: ________________________________________________________
Contact Person: __________________________________________________________________
Address: ________________________________________________________________________
City/State/Zip Code: ______________________________________________________________
Phone Number: ____________________________ Fax Number: ___________________________
E-Mail Address: ________________________________________________________________
(Note: Sponsoring AAA will be responsible for facilitating notification & luncheon attendance of recipient.)
Please return this form no later than June 8, 2015 to Barbara Gordon, Awards Chair.
Barbara Gordon, Director
KIPDA AAAIL/ADRC
11520 Commonwealth Dr.
Louisville, KY 40299
OR
barbara.gordon@ky.gov
SOUTHEASTERN ASSOCIATION OF AREA AGENCIES ON AGING
2015 OUTSTANDING VOLUNTEER IN AGING AWARD
NOMINATION FORM
Nominee’s Full Name: _____________________________________________________________
Address: _________________________________________________________________________
City/State/Zip Code: _______________________________________________________________
Phone Number: _____________________________ Present Age: ___________________________
Occupation: ______________________________________________________________________
Place of Work: ____________________________________________________________________
Address: _________________________________________________________________________
City/State/Zip Code: _______________________________________________________________
Education: _______________________________________________________________________
Degrees: _________________________________________________________________________
Honors(Civic,Professional,Academic,etc) _______________________________________________
Organizations: ____________________________________________________________________
Elderly Advocacy Efforts: ___________________________________________________________
NARRATIVE ON NOMINEE (Include reasons person merits the award. Use extra pages as
necessary):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Will the nominee attend the SE4A Conference? Yes ______
No ______
(Be sure to attach the extra pages to the Nomination Form before submission for judging.)
Name of Sponsoring AAA: ________________________________________________________
Contact Person: __________________________________________________________________
Address: ________________________________________________________________________
City/State/Zip Code: ______________________________________________________________
E-Mail Address: __________________________________________________________________
(Note: Sponsoring AAA will be responsible for facilitating notification & luncheon attendance of award recipient.)
Please return this form no later than June 8, 2015 to Barbara Gordon, Awards Chair.
Barbara Gordon, Director
KIPDA AAAIL/ADRC
11520 Commonwealth Dr.
Louisville, KY 40299
barbara.gordon@ky.gov
SOUTHEASTERN ASSOCIATION OF AREA AGENCIES ON AGING
2015 SE4A AGING IMPACT AWARD
NOMINATION FORM
The SE4A Aging Impact Awards were established to recognize public officials who have made a
significant measurable impact on the quality of life of older adults through their leadership at the
local, regional/state or national level.
Nominee’s Full Name: __________________________________________________________
Home Address: ________________________________________________________________
City/State/Zip Code: ____________________________________________________________
Phone Number: ________________ Fax Number:_______________ E-Mail:_______________
Public Office Held: _______________________Year Term Ends_________________________
Occupation: ____________________Place of Work: __________________________________
Address: ______________________________________________________________________
City/State/Zip Code: ____________________________________________________________
Education: ____________________________________________________________________
Please check only one Award Category for which this person is being nominated:
National Aging Impact Award
Regional/State Impact Award
Local Impact Award
Criteria: (One or more of the following):
Award nominees must have made an observable or measurable impact on the quality of life of older
adults by providing leadership in one or more of the following categories:
1.Advocacy
2.Public Policy Change
3.Securing New or Additional Funding
4.Program Development
5.Cultural Enhancement
NARRATIVE ON NOMINEE (Not to exceed 2 pages typed and no less than a 10 point font
size) Please include the following information:
1. What is Impact on the quality of life of older adults that has resulted from the work of the
public official?
2. What are observable and/or measurable outcomes of the work done by the public official?
(State in terms of number or percentage of older adults impacted).
3. Accomplishments of nominee that relate to award criteria listed above.
Will the nominee attend the SE4A Conference? Yes ______
No ______
Name of Sponsoring AAA: ______________________________________________________
Contact Person: ________________________________________________________________
Address: ______________________________________________________________________
City/State/Zip Code: ____________________________________________________________
E-Mail Address:________________________________________________________________
(Note: Sponsoring AAA will be responsible for facilitating notification & luncheon attendance of recipient)
Please return this form no later than June 8, 2015 to Barbara Gordon, Awards Chair.
Barbara Gordon, Director
KIPDA AAAIL/ADRC
11520 Commonwealth Dr.
Louisville, KY 40299
OR
barbara.gordon@ky.gov
SOUTHEASTERN ASSOCIATION OF AREA AGENCIES ON AGING
2015 AGING NETWORK AWARD
NOMINATION FORM
Nominee’s Full Name: __________________________________________________________
Address: ______________________________________________________________________
City/State/Zip Code: ____________________________________________________________
Phone Number: ________________________________________________________________
Occupation: ___________________________________________________________________
Place of Work: _________________________________________________________________
Address: ______________________________________________________________________
City/State/Zip Code: ____________________________________________________________
Education: ____________________________________________________________________
Degrees: ______________________________________________________________________
Academic Honors, etc. ___________________________________________________________
Organizations: _________________________________________________________________
Elderly Advocacy Efforts: ________________________________________________________
Leadership Roles:_______________________________________________________________
NARRATIVE ON NOMINEE (Include reasons person merits the Award.):
______________________________________________________________________________
______________________________________________________________________________
Will the nominee attend the SE4A Conference? Yes ______
No ______
(Additional sheets may be used. Limit is three pages; double space, 12 point font. Be sure to
attach them to the Nomination Form before submission for judging.)
Name of Sponsoring AAA: ______________________________________________________
Contact Person: ________________________________________________________________
Address: ______________________________________________________________________
City/State/Zip Code: ____________________________________________________________
E-Mail Address:________________________________________________________________
(Note: Sponsoring AAA will be responsible for facilitating notification & luncheon attendance of award
recipient)
Please return this form no later than June 8, 2015 to Barbara Gordon, Awards Chair.
Barbara Gordon, Director
KIPDA AAAIL/ADRC
11520 Commonwealth Dr.
Louisville, KY 40299
barbara.gordon@ky.gov