2011 Volunteer Service Award Application

GOVERNOR’S
AWARD

FOR
VOLUNTEER SERVICE

2011

Managed by the NC Commission on Volunteerism and
Community Service

Office of the Governor and the Cape Fear Volunteer Center

GOVERNOR’S AWARD FOR
VOLUNTEER SERVICE

2011

And

New Hanover County Volunteer of the Year
Award

NOMINATION
GUIDELINES

ELIGIBILITY

1. Nominees
must have been engaged in volunteer activities for a minimum of one year in
North Carolina and benefited a community or communities in the state in a
substantial, important or unique way.

2. Students
receiving course credits for their volunteer activities are ineligible
unless the nomination is based upon volunteer service that extends beyond
the course requirements, in which case it must be clearly indicated in the
nomination statement.

3. Previous
award recipients from within the past 10 years are
ineligible.

4. Those who
received compensation for their service are ineligible, with the exception of
paid Directors of Volunteers.

5. Nomination
cannot be based upon court-mandated community service.

6. Nomination
cannot be based upon serving as a “loaned executive.”

7. Self-nominations
are not permissible.

8. Nominators
cannot be family members.

9. Group/team
and corporate volunteerism nominations must be made by those external to the
group/team or corporation/business.

10. Nomination
submission requirements must be met.

SUBMISSION
REQUIREMENTS

1. All
nominations must be submitted on the 2011 Governor’s Award for Volunteer Service
nomination form.

2. The
nomination form consists of six sections and three supplemental pages. All required sections of the nomination
form must be completed.

3. The
nomination form must be typed (no smaller than 11-point
font).

4. Additional
materials such as photographs, news articles, etc. will not be accepted by the
Commission. Award selection will be
based solely on information provided on nomination forms.

5. The
deadline for county coordinators to submit nominations to the Cape Fear
Volunteer Center 1213 Culbreth Drive Suite 233 Wilmington NC 28405. Each county
will establish a local deadline for accepting nominations. Deadline for
submissions in New Hanover County is January 25, 2011 by 5pm. 5 hard copies must be
submitted.

AWARD
SELECTION

· Award
selections are based on the nominee’s volunteer efforts and commitment of time,
accomplishments, community impact and enhancement of the lives of others, as
described on the nomination form.

· Nominations
are evaluated at the county level. The top five nominations are submitted to the
Commission as nominees for the Governor’s Volunteer Service Award; one of the
five nominations may be recommended for consideration for the Medallion Award,
the state’s highest level of volunteer recognition. Each county may also recommend one
non-volunteer (paid) Director of Volunteers to be recognized at the Medallion
Award ceremony.

· The
Commission selects recipients of the Governor’s Volunteer Service Award, based
on the selection criteria.

· Under the
direction of the Commission, a statewide panel evaluates nominations for the
Medallion Award and the Director of Volunteers.

· Recipients
of the Governor’s Award for Volunteer Service, Medallion Award and Director of
Volunteers are selected based on merit – without regard to race, religion,
gender, national origin, or physical/mental disability.

GOVERNOR’S
AWARD FOR VOLUNTEER SERVICE

2011

NOMINATION
FORM

From County

SECTION
1 – NOMINATION CATEGORIES (COMPLETION
REQUIRED)

VOLUNTEER
SERVICE CATEGORIES

*Your
nominee may fit multiple categories; please select ALL that apply to
their service.

Individual: An individual
volunteer.

Family: A family that volunteers together on the same
project(s).

Group/Team: A group or team of two
or more people that volunteer together on the same project(s) under a group or
team name.

Youth Volunteer: A person (age 18 or younger) who
volunteers.

Senior
Volunteer: A person (age 55 or old)
who volunteers.

Perseverance in Volunteerism: An individual volunteer who has overcome significant
personal obstacles (mental or physical) in order to engage in service to others.

National Service Volunteer: An individual member of a National Service program
(AmeriCorps, AmeriCorps VISTA, AmeriCorps NCCC or Senior Corps) who has
demonstrated outstanding volunteer service above and beyond the
requirements of the designated program.

Outstanding Mentor: An individual volunteer who has demonstrated a
commitment to working with children (ages 18 and younger) in a mentoring
capacity and/or been actively engaged in other activities that support a
mentoring program.

Faith-Based Volunteer: An individual, group or team that volunteers through
a faith-based community organization.

Corporate Volunteerism: A business or corporation that
has made a substantial impact in the community by promoting service to their
employees by providing volunteer hours or engaging in other volunteer
activities.

Lifetime Achievement: An individual who has exhibited a lifelong
commitment to volunteerism and community service. Nominees must have made a
substantial and sustained impact in the community as a result of their service
efforts.

NON-VOLUNTEER
SERVICE CATEGORY

Director of Volunteers: A paid staff member who exceeds expectations of good
management skills in volunteer recruitment, training, coordination, risk
management, evaluation, retention and recognition.

Related job
titles could include Manager of Volunteers or Volunteer Program Director.

SECTION
2 – NOMINEE INFORMATION (COMPLETION
REQUIRED)

PLEASE
COMPLETE ONE BOX ONLY

PLEASE
COMPLETE THIS BOX FOR VOLUNTEER SERVICE IN THE FOLLOWING CATEGORIES: Individual, Youth, Senior, Perseverance in
Volunteerism, National Service,

Outstanding
Mentor, Faith-Based Volunteerism or Lifetime
Achievement

Title: Ms. Mrs. Mr. Dr. Other ________________________________________

Nominee’s
First Name________________________________________________________________

Middle
Name (if
applicable)_____________________________________________________________

Last
Name___________________________________________________________________________

Suffix Jr. Sr. III Other ________________________________________________

Home
Address ____________________________________________________________________

_______________
____________________________________________________

City _________________________________ State ______ Zip ___________ Phone _________________

PLEASE
COMPLETE THIS BOX FOR VOLUNTEER SERVICE IN THE FOLLOWING
CATEGORIES:

Group/Team
or Corporate Volunteerism

Group/Team
or Business Name (e.g. Smith
School Volunteers)_______________________________

Suffix (if
applicable) Co. Inc. LLC Other_________________________

Contact’s
Title Ms. Mrs. Mr. Dr. Other _________________________

Contact’s
First Name__________________________________________________________________

Contact’s
Last Name__________________________________________________________________

Suffix
Jr. Sr. III Other ________________________________________________

Address
Line 1 _____________________________________________________________________

_____________________________________________________________________

City _________________________________ State ______ Zip __________ Phone
_________________

NOTE: If the group/team or corporation/business is
a Medallion recipient, the contact person listed above will accept the award on
behalf of the group/team or corporation/business.

PLEASE
COMPLETE THIS BOX FOR NON-VOLUNTEER SERVICE IN THE FOLLOWING
CATEGORY:

Director of
Volunteers (paid staff member)

Title: Ms. Mrs. Mr. Dr. Other:

Nominee’s
First Name________________________________________________________________

Middle
Name (if
applicable):____________________________________________________________

Last
Name___________________________________________________________________________

Suffix: Jr. Sr. III Other ________________________________________________

Home
Address ____________________________________________________________________

____________________________________________________________________

City _________________________________ State ______ Zip _________ Phone ____________________

Agency/Organization
(Employer) ____________________________________________________________

Address ___________________________________________________________________________________

City _________________________________ State
______ Zip ________ Phone ____________________

Supervisor’s
Name _________________________________________________________________________

SECTION
3 – NOMINATOR AND REFERENCE INFORMATION (COMPLETION REQUIRED)

NOMINATOR

Name
________________________________________________________________________

Relationship
to Nominee (i.e.
volunteer supervisor)
_____________________________________________

Address
______________________________________________________________________

______________________________________________________________________

City
__________________________________ State ________ Zip
_____________________

Phone
________________________ Email
__________________________________________

Signature
______________________________________________ Date
__________________

REFERENCES

Two
references that are familiar with the nominee’s volunteer service are required.

REFERENCE
#1

Name
________________________________________________________________________

Relationship
to Nominee __________________________________________________________________

Address
______________________________________________________________________

______________________________________________________________________

City
__________________________________ State ________ Zip
___________________

Phone
________________________ Email
__________________________________________

Signature
______________________________________________ Date
________________

~AND~

REFERENCE
#2

Name
________________________________________________________________________

Relationship
to Nominee __________________________________________________________________

Address
______________________________________________________________________

______________________________________________________________________

City
__________________________________ State ________ Zip
____________________

Phone
________________________ Email
_________________________________________

Signature
______________________________________________ Date
________________

SECTION
4 – ORGANIZATION INFORMATION (COMPLETION REQUIRED)

Organization(s)
where nominee served:

*Except for lifetime achievement
nominees, please focus on this past year of service
only.

Organization 1

Organization
Name ___________________________________________________________

Volunteer
Job Title(s)_________________________________________________________

Dates of
Service______________________________________________________________

Total
length of time nominee has served this organization_______________________

Nominee’s
typical frequency and duration of service (e.g. 5
hours per day for 3 days

each
week)____________________________________________________________________

_____________________________________________________________________________

Nominee’s
primary volunteer duties____________________________________________

_____________________________________________________________________________ ___________________________________________________________________________

_____________________________________________________________________________

*If nominee
has served at more than one organization this year, please complete

the supplemental page of this nomination
form.

SECTION
5 – NOMINATION STATEMENT (COMPLETION
REQUIRED)

*Except for lifetime achievement
nominees, please focus on this past year of service
only.

Please
explain the main reasons this nominee is being nominated.

__________________________________________________________________

SECTION
6 – DESCRIPTION OF EXEMPLARY SERVICE (COMPLETION REQUIRED)

*Except for lifetime achievement
nominees, please focus on this past year of service
only.

Every volunteer is worthy of
recognition. Please summarize the nominee’s exemplary
service and describe what distinguishes this nominee’s efforts from other
volunteers by providing the following required information.

<> <> <>

Please describe the nominee’s outstanding commitment
to volunteerism and the agency or organization they have served. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

<> <> <>

Please describe the nominee’s outstanding
accomplishments and how the impact of their service has helped to meet critical
needs in their community.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SUPPLEMENTAL
PAGE – ADDITIONAL ORGANIZATIONS SERVED BY
NOMINEE

*Except for
lifetime achievement nominees, please focus on this past year of service
only.

Nominee
Name: ______________________________ County
_____________________

ORGANIZATION
2

Organization
Name _________________________________________________________

Volunteer
job title(s)__________________________________________________________

Dates of
Service______________________________________________________________

Total
length of time nominee has served this organization_______________________

Nominee’s
typical frequency and duration of service (e.g. 5
hours per day for 3 days

each
week)____________________________________________________________________

_____________________________________________________________________________

Nominee’s
primary volunteer duties____________________________________________

_____________________________________________________________________________

___________________________________________________________________________

ORGANIZATION 3