Hagedorn Service Award:

Recognizing Selfless Service NOMINATION FORM Description

The Hagedorn Award: Recognizing Selfless Service is an annual award honoring members of the Spring Grove Village community who are actively involved in altruistic service. The Hagedorn Award was introduced in April 2010 when it was presented to its namesake, Dr. Suzanne M. Hagedorn. Sue is the epitome of selfless service. Demonstrations of her selflessness include serving as the Board President for Winton Place Youth Center, where she also takes on the self-assigned task of cleaning bathrooms. She is known for working in the Spring Grove Village Community Garden, sharing medical insight and making meals for the elderly. Sue, however, shuns any special attention for her good worksa personal quality hoped to characterize future nominees. In many ways, our community gains more from this recognition program than the individual who receives the award. The nomination process and presentation of the Hagedorn Award are intended to encourage community members to pause, recognize and reflect on selfless servers who are role models for us all.

Guidelines and Instructions:

Nominations may be made by anyone who wishes to recognize a role model of selfless service in our community. An individual may receive multiple nominations. Please complete all sections of this form, including the eligibility checklist. Please type or print neatly. Electronic forms will be available at www.wpyouthcenter.net. All submittals must be postmarked, hand-delivered or received by email, no later than the stated deadline. (See bottom of form for details.) Email submittals (with a copy to yourself) are strongly encouraged to insure safe receipt of the nomination by the deadline. Finalists will be notified in April. The award winner will be recognized at the Winton Place Youth Center Annual Brunch with a perpetual trophy and gift certificate.

Eligibility Checklist
Does the potential nominee meet the following criteria?
Yes No

The nominee is a community volunteer residing in or serving Spring Grove Village. The nominee makes an outstanding community contribution through volunteer service. The nominee demonstrates exceptional commitment to service without expectation of reward. The nominee is not paid for performing the services to be recognized by this award. The nominee is a positive role model for members of our community.

If all of the above statements are true of the nominee, s/he is eligible for nomination. Phone: _________________________ Cell Phone: _____________________ Email: __________________________

Nominators Name: __________________________________ Relationship to Nominee (friend, co-worker, etc.) _________________

Address: ________________________________________________________________________ City: __________________________________________ State: ________ Zip: ____________

(rev. 3.26.12)

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Nominees Name: __________________________________ Phone: _________________________ Email: ___________________________________________ Cell Phone: _____________________ Address: ________________________________________________________________________ City: __________________________________________ State: ________ Zip: ____________

Give an overview of up to three areas of service:

Organization or Place of Service: _____________________________________________ Organizations Street Address: _______________________________________________ Zip _________ Brief Description of Type of Service _____________________________________________________ # of Years _______ Avg. # Hours/Yr. ________ Organization or Place of Service: _____________________________________________ Organizations Street Address: _______________________________________________ Zip _________ Brief Description of Type of Service _____________________________________________________ # of Years _______ Avg. # Hours/Yr. ________ Organization or Place of Service: _____________________________________________ Organizations Street Address: _______________________________________________ Zip _________ Brief Description of Type of Service _____________________________________________________ # of Years _______ Avg. # Hours/Yr. ________

On a separate piece of paper, please tell us about the nominee. Nominations will be reviewed by a third party, so be sure to provide helpful details highlighting the nominees service. Information on the following should be included:
I) II)
III)

Does the nominees work meet a particular need in the community? Please explain. What makes this individuals efforts special? What is the impact of the service? What affect, outcomes or change have resulted?

IV) What other relevant information should be considered?

(Responses of 250-500 words are appreciated but not required. Please provide examples as often as possible. Information may be used in public announcements related to this award. )

Optional: Supporting documentation (e.g. certificates, newspaper articles, event photos, etc.) may be attached, but are not required. All materials become the property of the award committee and will not be returned. Please list any such attachments below.

I affirm that all statements and implications offered herein are true to the best of my knowledge. I understand that all nomination materials become the property of the award committee and may be used for reporting or promoting the Hagedorn Award program. Signature of Nominator: ______________________________________________ Date: ______________________

(rev. 3.26.12)

The deadline for submission is: NOON, Friday,

April 6, 2012.

Submit nomination forms by email to daviswpyc@gmail.com or mail to Winton Place Youth Center, 4609 N. Edgewood Avenue, Cincinnati, Ohio 45232.
Please retain a copy of all materials for your records.