The Denise House Celebration of Courage Nomination Form
 

Throughout the past three and a half decades, hundreds of volunteers, supporters and community leaders have contributed to the success of the women and children we serve.

* Some have directly donated gifts or volunteered their time.  
* Some have worked to raise awareness and prevent violence against women.
* Some are women who have set an example of empowerment and success.

In 2019 The Denise House celebrates 35 years of courageous women and community members.

Tell us who you feel deserves special recognition.

We're selecting 35 community members to be honoured at a special celebration in March 2019.

A short nomination form follows for your completion.  Nominations will be accepted until November 30, 2018.

*PLEASE NOTE - BY FILLING IN THIS FORM YOU ARE AGREEING THAT THE NOMINEE IS AWARE OF THE NOMINATION AND IS PROVIDING CONSENT FOR THE DENISE HOUSE TO UTILIZE NAMES/PHOTOS FOR PROMOTIONAL REASONS.

 
 
1.
YOUR Information  (Person filling out Nomination)

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Company Name:
Home Phone:
Email Address:
emailaddress@xyz.com

2.

Name of NOMINEE (if different from nominator)

 

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3.

Email Address of Nominee 

 

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4.

Phone Number of Nominee

 

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5.
Your Relationship to Nominee and length of time
 

50 characters left.
Choose one or all three of the next 3 questions to help us understand your nomination.
Please provide relevants dates, context, background for your story.

If you do not have sufficient space, you can email supporting documents to:

mguy@thedenisehouse.com 
Subject line : Courage Nominee (full name of the Nominee)


If you need assistance in filling out the form, please call Melanie at The Denise House, 905-728-7311
 
6.
Nominee provides or has provided significant support to The Denise House (ie. volunteer, increasing awareness of The Denise House)
 

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7.

Nominee has worked in the community to raise awareness and/or prevention of the issue of violence against women (ie. brings caring and respectful services to victims of violence; has demonstrated commitment to women's equality, safety and rights; has participated in developing programs, projects and partnerships to offer services to victims of violence).

 

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8.

Nominee has displayed an example of Courage, Empowerment and/or Success (especially after adversity) 

 

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9.

Please provide any additional comments in support of your nominee

 

1000 characters left.