The 21st Annual Shine A Light on Child Abuse Awards Breakfast Nomination Form
Deadline: 5 pm on Friday, February 8, 2019

If you have any questions regarding the nomination form, please contact Janki Patel at (909) 383-9651 or by email: janki.patel@hss.sbcounty.gov

Email address *
Nominee Information
Please fill out the information below regarding the person or agency you are nominating.
Nominee First AND Last Name *
Your answer
Nominee Work Address *
Your answer
Nominee Email Address *
Your answer
Nominee Phone Number *
Your answer
Nominee Agency/Organization *
Your answer
Nominee Job Title *
Your answer
Nomination Category *
Required
Describe Nominee's Qualifications
In addition to providing the information above, please include the work s/he performs, his or her unique contributions to the work done that goes beyond the duties of his/her job, along with their special relationships with children and youth.

(Minimum 300 words, Maximum 800 words)

Nominations with less than 300 words will not be accepted.

Please provide your write-up in the space provided below. *
Your answer
Nominator Information
Please provide your information below. This is how I can contact you with any questions.
Nominator First AND Last Name *
Your answer
Nominator Address *
Your answer
Nominator Email Address *
Your answer
Nominator Phone Number *
Your answer
Nominator Agency/Organization *
Your answer
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