St. Vincent Family Centers

Corcoran Award Nomination Form

Eligibility requirements: Winners of the Corcoran Awards must show outstanding involvement and measurable impact as a result of his/her individual efforts to advance the causes of behavioral health, children’s issues, early childhood or elementary education, social justice, or the work of the Catholic Church. Individuals nominated for the award must be in good standing in the central Ohio community. Additional pages may be added to this form but nominations should not be more than 5 pages long. The nominations will be reviewed by a committee of community leaders. Receipt of the award is contingent on the winner’s availability on November 11, 2009.

Award area of emphasis for this nominee (circle one):

Behavioral Health Children Education Social Justice Catholic Causes

Nominee ________________________________________________________

Title First Middle Initial Last

Position _________________________________________________________

(Position can be the nominee’s volunteer role or professional title.)

Organization:_____________________________________________________

(Organization can be the nominee’s volunteer or professional affiliation.)

Number of years in this role: ____________ Daytime phone: ______________

Nominator: _________________Nominator e-mail: ______________________

Please describe your relationship to the nominee including length of time you have known the nominee: _______________________________________________

Please describe the work for which you are primarily nominating this individual. Be as specific as possible about the nature and duration of the work and why the work is important to the central Ohio community.

Why do you believe the nominee’s work has made an impact on the area of emphasis? (Please provide examples of measurable impact, i.e. positive changes that occurred in numbers served, quality of care, or other specified success measures as a result of the nominee’s direct involvement and leadership.)

Please indicate any other reasons why you believe this nominee is deserving of this award. (Examples include other achievements in the nominee’s personal or professional life, overcoming personal hardships, or additional information about the candidate that adds insight into the nominee’s character or motivations.)

Thank you for your nomination.

Please return this form by September 4, 2009 to:

Susan Brehm, VP/Chief Advancement Officer, St. Vincent Family Centers, 1490 E. Main Street, Columbus, Ohio 43205 or e-mail to sbrehm@svfc.org Ticket information is also available at this address.

Little Kids…Big Tomorrows