The Arc New York 2024 Dr. John Kowalczyk Outstanding Citizenship Award

Dr. John Kowalczyk Outstanding Citizenship Award Nomination Form

NOMINATION DEADLINE: Friday, July 19, 2024

About the Award: This award is designed to highlight and celebrate individuals supported by their local Arc New York Chapter by recognizing their achievements and contributions made to their local Chapter, community and/or peers. Nominees and recipients are individuals who not only use services provided by their local Chapter of The Arc New York, but also help to provide support to others in a manner that benefits other people with intellectual or developmental disabilities and their community. One (1) award in the amount of $500, along with a commemorative personalized glass award is presented annually.

Eligibility Criteria:

The nominee must have an intellectual or developmental disability
The nominee must have a connection to a Chapter of The Arc New York Organization
One nomination may be submitted for each county within a Chapter
The nominee should for example, be an individual who is recognized to be someone that exemplifies the following: peer advocacy, a community supporter, someone who participates in organizing and/or supporting events at the Chapter level, or an overall positive support for others in their community circle

Application Requirements:

Completed application
One (1) peer letter of support must be included. Up to two (2) additional letters from others may be included if desired

The Arc New York Dr. John Kowalczyk Outstanding Citizenship Award will be presented during the luncheon at the October Annual Meeting.

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* 1. Nominee Information

Nominating Chapter

Chapter County

Name of Nominee

Chapter Address

Submitter Email Address

Phone Number

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* 2. How has the nominee directly or indirectly helped to enable others with IDD achieve their own personal outcomes (goals/growth)?

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* 3. What groups or Chapter/community activities is the nominee currently involved in?

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* 4. How has the nominee helped to support others through active participation of events and interactions? (Specific actions and characteristics or approach)

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* 5. Explain the nominee’s level of involvement in providing support to their peers, Chapter events, and/or community events.

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* 6. What challenges within your Chapter and/or community has the nominee recognized and taken steps towards improving or establishing support?

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* 7. Contact information for person making this nomination:

Name

Title

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* 8. Digital Signature of person making this nomination - Please type your full name and the date into the field below as your electronic signature (ex. Jane Doe, 8/25/2021)

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* 9. Upload Letter of Recommendation 1

If you don't have a digital copy of your letter available at this time, you can email it separately to the address below

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 10. Upload Letter of Recommendation 2

If you don't have a digital copy of your letter available at this time, you can email it separately to the address below

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Please email any additional documentation or questions to:

Christina Canino
Senior Project Coordinator
The Arc New York State Office
Email: CaninoC@TheArcNY.org