Certificate of Appreciation 2016 Nomination Form

Autism Nova Scotia is proud to represent a network of support for individuals with autism, their families, educators, healthcare professionals, researchers, employers, and the broader community. We believe that providing parents and people with autism with accurate information and an improved understanding of Autism Spectrum Disorders (ASD) fosters the opportunity for success. In this spirit, every year we are pleased to recognize the achievements and innovation of autism ambassadors or advocating groups who are dedicated to the support, development and success of an individual with ASD.

Thank you for taking this opportunity to recognize outstanding achievement in support of the autism community in Nova Scotia. Nominees for the Certificate of Appreciation Award may be an individual or group who has demonstrated the ability to positively and collaboratively foster learning and play opportunities, build self -esteem, peer relations, and provide meaningful support to individual/s with autism.

• Provides learning and play opportunities to meet the individual’s needs• Actively consults and supports the family and professionals

• Builds self-esteem and peer relations for the individual with autism• Continues to seek and utilize accurate information about autism

• Understands and respects the uniqueness of the individual with autism

If you would like to nominate an individual, school or group for the Certificate of Appreciation Award, please complete the attached nomination form and submit it via email, fax or by mail to

the attention of Allison Bain, Events & Communications Coordinator | abain@autismns.ca.

Autism Nova Scotia is located at 5945 Spring Garden Road, Halifax, Nova Scotia B3H 1Y4 T: 902.446.4995F: 902.446.4997 Toll Free in Nova Scotia: 1.877.544.4495 www.AutismNovaScotia.ca BN: 891950305RR0001

Certificate of Appreciation 2016 Nomination Form

Name: ________________________________________________________ Date: _____________________

Mailing Address: _____________________________________________ City: _______________________

Province: ____________________________________ Postal Code: ________________________________

Phone: ________________________________ Email: ___________________________________________

• Please identify your relationship to nominee:Parent: � Student: � Other � _______________________________ (Please specify)

• Please identify the academic environment of the nominee:Public School: � Private School: � Other: � ______________________________ (Please specify)

• Name of academic organization (if applicable): _______________________________________________

Nominee Information

Please provide the name and contact information for the individual that you are nominating forAutism Nova Scotia’s Certificate of Appreciation Award:

Name: _____________________________________________ Phone: _______________________________

Email: ___________________________________________

In approximately 500 words or less, please describe how your nominee exemplifies the criteria of the Certificate of Appreciation Award. Nominations must be submitted by Thursday, November 17, 2016.

Certificate of Appreciation 2016 Nomination Form

Nomination Continued...