YMCA 2009 PEACE MEDAL NOMINATION FORM

Name of Person or Group making nomination: ________________________________________

If Group, name of contact person: __________________________________________________

Phone:  (W) ______________________________ (H) __________________________________

I/we have received the criteria for the YMCA Peace Medal and wish to nominate

______________________________________________________________________________

Note: Details regarding the nominee’s contributions and accomplishments must be included.  Please see guidelines: How to nominate an individual or group – criteria and process.

References:

Name: _____________________________________ Phone: ____________________________

Name: _____________________________________ Phone: ____________________________

In order for the nomination to be considered by the Selection Committee, the nominee must give permission for his/her/their name to be put forward.  Please indicate that such permission has been received.

I/WE HAVE THE PERMISSION OF THE NOMINEE(S) TO PUT HIS/HER/THEIR NAME FORWARD.

______________________________________________________________________________

Signature of Nominator

DEADLINE FOR NOMINATIONS: November 15, 2009

Forward to:     Lethbridge YMCA

                        Attn. Jaime Griffin

                        515 Stafford Dr. S.

                        Lethbridge, AB

                        T1J 2L3

Fax to:             Jaime Griffin at 403-320-6475