2. 

4. Person Submitting Information

6. Name*
7. Address*
9. Phone Number*
10. Email*

12. Nominee

14. Name*
15. Address*
17. Phone Number*
18. Email*
20. Is the nominee 18 years or older?*

    1. Yes
    2. No

22. If under 18 years old, please provide parent/guardian contact information.

24. Name
25. Address
27. Phone Number
28. Email
30. Short statement: 50-500 words on why this person or organization is being nominated. Describe how they are making a difference in the lives of individual with disabilities in Aurora.*
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field