Instructions - Adult Nominations
2020 Eugene Policelli Service Award Nominations - ADULTS. You are nominating a South Windsor community member who has demonstrated a commitment to volunteerism in the South Windsor community. This nomination form may be submitted by an employer, a school employee, a community member or a member of the organization for whom this person provides volunteer/community service. A family member cannot submit a nomination.

Eligibility: The nominee must be a resident of South Windsor for the past three years or have worked and/or volunteered in South Windsor for at least three years; be an example of outstanding citizenship; have made a significant contribution to enhancing the quality of life in South Windsor; and have provided community service in the town of South Windsor over a period of at least three years.

Please provide all information requested, including specific details regarding the nominee's volunteer service activities. (Space is provided for up to three different organizations; if more space is needed, please write in the comment field below.)

The following criteria will be used to evaluate the candidate's qualification for this award:
1. Impact on the Community: Was the nominee’s contribution substantive enough to make a difference in the
organization and the community?
2. Amount/Depth of Service: Does the nominee appear to have demonstrated a long-term commitment to one
or more community service activities?
3. Leadership: Has the nominee assumed a leadership role in the community service activity?

The nomination deadline is February 28, 2020. Incomplete applications will not be accepted. All information will be verified before it is submitted to the selection committee for review. Award recipients will be notified by April 6, 2020.

Email address *
Nominee Name *
Your answer
Nominee Address *
Your answer
Nominee Phone *
Your answer
Nominee Email *
Your answer
Nominator (Your) Name *
Your answer
Nominator Address *
Your answer
Nominator Phone *
Your answer
Nominator Email
Your answer
Relationship to Nominee *
Your answer
Volunteer Service Verification - Organization #1
Description of Nominee's Voluntary Service
1. Name of Organization Served (include address, if known, and description if not obvious by title) *
Your answer
2. How long has the nominee been involved with and volunteered for this organization (be as specific as possible - years? hours per week?) *
Your answer
3. Whom can we contact to verify the nominee's service? *
Your answer
3a. Organization Contact's Phone Number *
Your answer
3b. Organization Contact's Email *
Your answer
4. Describe in detail the services provided by the nominee, including the work done for the organization, the impact it had on the organization(s) and/or the community, the time commitment made, and how many people were impacted by the service. *
Your answer
5. Did the nominee have a leadership role in this activity or within this organization?
Volunteer Service Verification - Organization #2
Description of Nominee's Voluntary Service
1. Name of Organization Served (include address, if known, and description if not obvious by title)
Your answer
2. How long has the nominee been involved with and volunteered for this organization (be as specific as possible - years? hours per week?)
Your answer
3. Whom can we contact to verify the nominee's volunteer service?
Your answer
3a. Organization Contact's Phone Number
Your answer
3b. Organization Contact's Email
Your answer
4. Describe in detail the services provided by the nominee, including the work done for the organization, the impact it had on the organization(s) and/or the community, the time commitment made, and how many people were impacted by the service.
Your answer
5. Did the nominee have a leadership role in this activity or within this organization?
Volunteer Service Verification - Organization #3
1. Name of Organization Served (include address, if known, and description if not obvious by title)
Your answer
2. How long has the nominee been involved with and volunteered for this organization? (be as specific as possible - years? hours per week?)
Your answer
3. Whom can we contact to verify the nominee's volunteer service?
Your answer
3a. Organization Contact's Phone Number
Your answer
3b. Organization Contact's Email
Your answer
4. Describe in detail the services provided by the nominee, including the work done for the organization, the impact it had on the organization(s) and/or the community, the time commitment made, and how many people were impacted by the service.
Your answer
5. Did the nominee have a leadership role in this activity or within this organization?
To your knowledge, has this person been nominated previously for a Eugene Policelli Service Award?
Comments or notes (if applicable):
Your answer
Finished? Thank you for completing this nomination form.
Once complete, please "Submit." You will receive a confirmation email within three (3) business days to acknowledge receipt of your nomination form. If you have any questions or problems, please contact Sara Chamberlain at schamberlain@swindsor.k12.ct.us or (860) 291-1204.
Submit
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