Elder Caregiving Award Nomination

The Elder Caregiving Award symbolically honors the thousands of Ohio caregivers who lovingly take care of family and friends day after day. Although the award is only given to a few caregivers, it heightens public awareness of the contributions of all caregivers.

Criteria:

Either the caregiver or recipient of care must be age 60 or older.
Care provided by the nominee must not be job-related.
Nominations may be made by an individual or an organization. Self nominations will not be considered.

To nominate an outstanding caregiver, simply complete and submit the form below. Alternately, you can download the nomination form to fill out and fax or mail in.

All fields, except where noted, are required.

Caregiver's name:
Street address:
City, state, ZIP:
County of residence:
Phone:

Care recipient's name:
Street address:
City, state, ZIP:
County of residence:
Phone:
Relationship to caregiver (if applicable):
Birth Date:

Describe the care recipient's condition:

Describe details about the care provided by the caregiver:

How long has care been provided?

How does the care provided impact the recipient and his or her family?

Describe special circumstances or barriers the caregiver faces:

List the sources and types of care assistance provided by others:

In 300 words or less, describe your reasons for nominating this caregiver.

Nominator's name:
Organization (optional):
Street address:
City, state, ZIP:
County of residence:
Phone:
E-mail (optional):

By clicking the submit button below, you certify that the information above is true and accurate. Nomination forms must be received by November 1. All nominations received after this date will be held for the following year. Please refer to our Privacy Statement for details about information sent electronically.