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North Carolina Leadership Achievement Award 2021 Nomination Application

The North Carolina Leadership Achievement Award is presented to an outstanding North Carolina self-advocate whose work has improved the quality of life for people with intellectual and other developmental disabilities. The award will be presented at the quarterly meeting of the NC Council on Developmental Disabilities on November 3, 2021 in Cary, NC.

Section 1. Nomination Form

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Section 2. Listing of Qualifications

If necessary, please attach as a separate document a brief description (not to exceed 300 words) of the qualifications of the nominee for this award. Give specific information about the nominee’s activities in improving lives of people with intellectual or other developmental disabilities, including examples of significant contributions and leadership. Please include the following:

  • List nominee’s advocacy experience
  • Areas of strength/experience/achievements in the area of intellectual or other developmental disabilities.
  • List nominee’s volunteer experience
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Section 3. Supporting Information

Identify three individuals who have knowledge of the efforts of the nominee.

NOTE: It is encouraged that individuals submit a short statement (maximum 300 words) in support of the nominee. Statements should include specific examples of work the nominee has done to influence positive change in the lives of people with intellectual and other developmental disabilities.

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2.
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3.
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Section 4. Personal References (Required)

Identify three (3) individuals as personal references who may be contacted to help evaluate the qualifications of the nominee.

Reference 1

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Reference 2

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Reference 3

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Section 5. Submission Deadlines and Requirements

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Submission Options: NOTE: all pages of this application must be submitted by Friday, July 30, 2021 in one of the three ways:

  • Email the application form to Philip C. Woodward, Systems Change Manager, at philip.c.woodward@dhhs.nc.gov and info@nccdd.org
  • Fax the completed application to 919-715-0325. Please include cover sheet indicating Full Name and total number of pages.
  • Mail the application to:
    North Carolina Council on Developmental Disabilities
    ATTN: NCCDD Advocacy and Leadership Awards, 2010 Mail Service Center, Raleigh, NC 27699-2010

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North Carolina Council on Developmental Disabilities
820 South Boylan Avenue
Raleigh, NC  27603
Info@nccdd.org
919-527-6500 (voice/tdd)
800-357-6916 (voice/tdd)
800-357-6916 (TTY)
919-850-2915 fax