Visionary Women Awards Nomination Form

Name of Nominee *

Nominee's Phone Number *

Nominee's Email Address *

Nominee's Address

Address 1

Address 2

City

State/Province

Zip

Nominee's Occupation/Place of Employment (if applicable)

Family Caregiver – Unpaid caregivers who are on the frontline (present or past) providing compassionate care to a loved one with Alzheimer’s or a related form of dementia.

Professional Caregiver/Direct Service – Paid caregivers who work on the frontline to provide compassionate care in the dementia field. This classification is appropriate for hospice workers, in-home care workers, RCFE employees, etc.

Administrative Professional – Individuals that serve as an administrative professional in a licensed residential care facility or related service agency that provide care to persons living with Alzheimer’s or related forms of dementia (hospice, in-home care, etc.).

Alzheimer’s OC Team Member – Staff/caregivers that work for Alzheimer’s Orange County, Healthy Aging Center: Acacia or Healthy Aging Center: Laguna Woods who exemplify compassionate care through the direct care or other forms of support they provided for the individuals and families the organization served.

Youth/Young Adult Caregiver – Unpaid caregivers (25 years and under) who provide regular care to a loved one with Alzheimer’s or a related form of dementia.

Please indicate the applicable nomination category: *

Family Caregiver
Professional Caregiver/Direct Service
Administrative Professional
Alzheimer’s OC Team Member
Youth/Young Adult Caregiver

Why are you nominating this individual? *

Describe the nominee's history of caregiving & the ways, places & circumstances where they provided compassionate care. *

What specific qualities make the nominee stand out as a caregiver (sensitivity, empathy, etc.)? *

Are you self-nominating? *

Yes
No

Your Name *

Your Phone Number *

Your Email Address *

Your Address

Address 1:

Address 2:

City:

State:

Zip:

Relationship to Nominee *

If you have photos or videos of the nominee, please email them to events@alzoc.org

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Visionary Women Awards Nomination Form