NASW/CT Latino/a Social Workers Network - 2020 Recognition Dinner Agency Nominations Form
THEME: Agencies Leading in Latinx Social Work

In 2020, the NASW/CT Latino/a Social Workers Network will be highlighting the top three (3) community-based or social service agencies in Connecticut that exemplify our organization’s purpose: (1) Provide a professional network for Latino/a social workers and others interested in issues relevant to Latino/a social workers and the Latino/a community; (2) Meet for sharing of mutual interests; and (3) Address issues of concern to Network members within the framework of the social work profession.

The Recognition Dinner will held on Thursday, March 26, 2020, 6pm-8pm, at 50 Elm Cafe & Spirits, 50 Elm St., Hartford, CT 06106. Registration and Sponsorship forms will be available in early January 2020.

We will be accepting nominations starting Friday, November 22, 2019. Our steering committee will make a final decision on the recipients in early February 2020. If your agency is one of the top three (3), you will be notified in mid-February 2020 and recognized at our March 2020 Recognition Dinner.

Recognition includes a plaque, ad in the NASW/CT chapter's Connections newsletter, ad on the chapter website, announcement on chapter's social media, chapter press release, and three (3) free tickets to the Recognition Dinner. An agency representative must be present to receive the recognition.

Please complete the following nomination form to be considered for our Network's recognition. This questionnaire will take approximately 30 minutes to complete. The deadline for submitting nominations is January 31, 2020.

If you have any questions or concerns while completing the form, please e-mail lswctnetwork@gmail.com.
1. Agency Name *
Your answer
2. Agency Type (e.g., mental health clinic or center, hospital, school-based, advocacy, higher education, etc.) *
Your answer
3. Primary Address (Street Address, City/Town, and Zip Code) *
Your answer
4. Catchment Area(s) Served (City/Town) *
Your answer
5. Agency Size (Number of Employees) *
Your answer
6. Full Name of Chief Executive Officer (CEO) or Executive Director (ED) *
Your answer
7. Agency Contact Person Name (Person Completing this Form). This must be a person the Network's Steering Committee can contact regarding your agency if it has been chosen as one of the top three (3) agencies. *
Your answer
8. Agency Contact Person Phone Number (Area Code + Phone Number) *
Your answer
9. Agency Contact Person E-mail (must be accurate and updated; if any changes, please immediately e-mail lswctnetwork@gmail.com) *
Your answer
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