Making a Difference Award - Nomination Form

“Making a Difference in the Multiple-Birth Community”

(Confidential when completed)

 Local Award
 National Award
 International Award
 Media Award
 Dionne Award
 Corporate Award
 Chapter Award

Nominee's Full Name:

E-mail:

Phone Number:


Select category (click here for more information on each category):


Please provide the following information in as much detail as possible:

  • Local / National and International  Reasons why you are nominating this individual; include positions the nominee has held within the organization(s), dates of active participation in the organization(s), professional activities or occupations with responsibilities, any official honours or awards received and any other information which will help the MADA committee make an informed decision before recommending recipients to the Board of Directors.
  • Dionne Award:  Reasons why you are nominating this individual or these individuals; include positions the nominee(s) has/have held in organizations, and the dates of active participation in such organizations, through which he/she/they demonstrated an ability to increase awareness of the challenges facing multiples (if applicable); any official honours or awards received; and any other information which will help the MBC Board of Directors to make an informed decision for this award.
  • Media Award  Reasons why you are nominating this media outlet and/or individual; include when the article(s) or story (ies) was/were printed/aired, the journalist who developed the story, and any other information which will help the MBC Board of Directors to make an informed decision for this award.
  • Corporate Award  Reasons why you are nominating this business or corporation; include as much information as possible as to how this business has made a difference to the multiple-birth community at the local or national levels, and any other information which will help the MADA Committee to make an informed decision in choosing a recipient for this award.
  • Chapter Award  Awarded to a chapter that has displayed outstanding dedication or has been responsible for outstanding accomplishments of significance to their local multiple births community. Multiple awards may be given based on the size of the chapter membership. Chapters are encouraged to self-nominate by submitting a short write up about a project or event that positively impacted their community.
Additional Information:
  • For all Nominations - Multiple Births Canada requests that where possible you include a photo of the Nominee (jpeg file).
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  • For all Nominations – please include any links/websites or other relevant information, where possible:
  • For the Media Award – please attach a copy of the newspaper articles or links to any online media.
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  • For the Corporate Award – please attach any pictures of the business owners or representatives, or presentations to or involvement with the multiple-birth community, logos for the business, or other important information that can be shared with the MADA Committee.

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Nominator's Full Name:

Your Email:

Your Phone Number:

(Please supply one contact person that can confirm information supplied):

Reference's Full Name:

Email:

Phone Number:

 

I confirm the above information is accurate and true to the best of my knowledge. This form, and the information contained therein, is confidential. By checking this box you are giving consent to the MADA Chair, to release your comments to the Nominee upon request. You are also digitally signing this application.

Digital signature information: The date, time and your IP address [54.204.129.35] will be recorded and sent upon submission.

Contact the MADA Nomination Committee if you need to make any changes to this nomination after submitting for review.

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Email: office@multiplebirthscanada.org

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