2010 ERIK COGSWELL MEMORIAL AWARD NOMINATION FORM This award is presented annually by the Erik Cogswell Memorial Conference Committee to recognize individuals for their outstanding contributions to help improve the lives of people with Bipolar Disorder and other mental illnesses. Recipients provide Hope, Education and/or Support for those living with mental illness, as well as those who care for them and the community at large. Nominations are made by completing and submitting this Nomination Form as described below. Nominee Qualifications • The contributions of nominees must demonstrate activities that support the conference mission and improve the lives of people with Bipolar Disorder and other mental illnesses. • Nominees must have made outstanding contributions to the community in one or more of the following areas: Hope, Education, and/or Support. • Nominations can be made to recognize an individual’s outstanding lifetime accomplishments and/or an individual’s outstanding contributions to the community at large. • Nominees may be consumers of mental health services, family/support system members, peer support providers, volunteers, and/or paid professionals. • The contributions of nominees can be made through volunteerism, paid work or both. • The award recognizes individuals and not organizations. However, the contributions of an individual can be made through their association with or work on behalf of an organization. • Ineligible for the award: organizations, self-nominated individuals, current members of the Bipolar Conference Committee, individuals on the Nominating and/ or Voting Committees, current Seacoast Mental Health Center staff or Board of Directors, prior award winners. SUBMIT NOMINATIONS TO DIANE CYR BY OCTOBER 15, 2010 Nominations received after this date will NOT be accepted Nominations can be typed or legibly handwritten Contact Diane Cyr at 603-957-5767 or dcyr@smhc-nh.org Mailing address: SMHC, 1145 Sagamore Ave., Portsmouth, NH 03801 Nominee Information Name: Organization (if applicable): Title/ Position (if applicable): Address: City: Daytime Phone:
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Nominating Individual/Organization Information Name: Organization (if applicable): Title/ Position (if applicable): Address: City: State: Daytime Phone: E-mail: Is the nominee aware this nomination has been submitted? Signature of Nominator (if mailed): 1
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Identify specific contributions that demonstrate the nominee’s contributions related to Bipolar Disorder and other mental illnesses in areas of Hope, Education and/or Support. Specifically include the nominee’s contributions in the area of Bipolar Disorder in your responses. Nominee Name: 1. Does this nomination recognize the individual’s lifetime accomplishments OR outstanding contributions to the greater community?
2. What does the nominee consider as their community? (e.g. specific town(s), statewide, region, organization, school district, etc.)
3. How has the nominee increased the knowledge base and understanding of Bipolar Disorder and other mental illnesses?
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4. How has the nominee provided hope and/or support to those living with Bipolar Disorder and other mental illnesses, those who care for them and/or their community at large?
5. What sets this nominee apart from other individuals?
6. What leadership skills does the nominee display?
7. How do you know the nominee?
8. Is there any additional information that would be useful for the committee to know about the nominee?
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