Primary care recipient information - Please provide all information requested. If the nominee provides care to more than one person, provide full information for the primary recipient here and list other names in the space provided. Again, birthdate will be used to determine eligibility only and will not be published or shared without consent.
Name:
Street address: County:
City/State/ZIP: Day phone:
Birthdate: E-mail:
Relationship to nominee:
How long has care been provided?
Are there additional care recipients? Yes No
Please list the names:
Nominator information - Please provide your contact information. If you are nominating on behalf of an organization, please note so along with your name. You will be notified if this nominee is or is not selected.
Name:
Street address: Day phone:
City/State/Zip: E-mail:
Organization (if applicable):
By checking the box below, you attest that you have verified that the information provided on this nomination form and any related attachments is factual and accurate.
I do so attest. Date:
Nominee's consent - By checking the box below, you attest that you have received consent from the nominee or his or her representative to submit this nomination. We may request a signature of consent to verify. Nominations without consent will not be considered.
I do so attest. Date:
Essay - Please type or paste below an essay that explains why you feel the nominee is worthy of receiving an Elder Caregiver Award. Your essay should be approximately 1,000 words. Include the following information as applicable:
Impact on caregiver and family – Explain how caregiving duties affect the nominee’s family, both positively and negatively, and describe how the caregiver maintains his or her own life balance. Examples include maintaining proper diet and personal medical care, engaging in social activities, working, worship, community involvement and personal time. Unique or innovative approaches to caregiving – Describe ways the caregiver "thinks outside the box" to make his or her efforts easier for himself or herself, or more beneficial to the recipient. Examples include technology, home modification, health care classes, modifications to existing equipment and coordinating care among family. Sources and types of care assistance provided by others – List the sources and types of assistance (e.g., respite services, area agency on aging services, Alzheimer’s Association services, etc.) this nominee uses to support his or her efforts and describe how this assistance helps both the nominee and the recipient. Describe respite services the caregiver receives, including respite given by family members and friends.Special circumstances or barriers – Explain factors that interfere or could interfere with the provision of care and describe the nominee’s approach to overcoming them. Examples include personal health, family situations, social pressures, financial limitations, etc.Impact of care provided to the recipient and his or her family – Describe how the caregiver has affected the recipient and his or her family, and what is being done to keep the recipient engaged with family, friends and community. Examples include attending religious services, family events, senior center activities, connecting using a computer via Facebook, etc.Severity of care recipient’s condition and degree of difficulty of care provided – Without divulging personal medical details, explain how the care recipient’s condition interferes with activities of daily living (e.g., dressing, bathing, grooming, eating, mobility, ability to socialize). Describe the degree to which he or she is dependent on others. Describe difficulties for the nominee to provide care.
