OPDI Lighthouse Award 2016 Nomination Form

Individual Award

Please print all information legibly and return by Sept 2nd, 2016!

1. Nominee Contact Information

Nominee Name: ______

Nomination for:  Unsung Hero Peer of the Year  Pay it Forward

Mailing Address: ______Postal code______

City: ______E-Mail Address: ______

Telephone Number: (_____)______Alternate number: (____)______

□I am aware of this nomination and approve my nominator collecting and forwarding the attached information about me. I have initialed each page of this submission.

□If I am selected to receive this award, I will attend the presentation in Toronto September 22nd, 2016. I understand that OPDI will cover costs of the most economical method of travel within Ontario and one night accommodationif required.

□A few days before the awards event, I will be provided a draft for my approval, of the information that will be presented about me at the event or publicly shared after the event.

I have never received any mental health/addictions related awards at the provincial level or beyond? True False, I have received ______(Please note, Unsung Hero category is for those who have NOT received recognition beyond local)

Nominee Signature (required)______
Note: to respect the nominee’s privacy, applications will not be read or considered unless all boxes above are checked and the nominee signs this form and initials each page of attached material.

2. Nominee’sOrganizational Affiliation
(note Unsung Heronominee must be a member or staff of an OPDI member group. See member list at or call 416 484-8785 ext 2 to confirm)

Org Name:______

 This organization is an OPDI member (necessary for Unsung Hero category)

Or

This organization embraces values similar to OPDI (see

Nominee’s Role:  Management  Staff  Volunteer  Member  Other______

Lead Staff Name:______

Lead Staff E-Mail: ______

Lead Staff Telephone Number: (_____)______

□I confirm that the nominee is a member in good standing of this organization
Signature of Staff lead ______

3. Nominator Information (if different from above)

Nominator Name:______

E-Mail Address: ______

Telephone Number:______

4. Nominee Information

We seek to honour someone with lived experience who, in your community and beyond, through their commitment and work has shown excellence. Please check all that apply to the work your nominee has been involved in, and flesh out your selections in 4a):

Unsung Hero Category

Peer support

Advocacy

Policy work

Governance, management
Volunteer contributions as well as paid

Public education

Recovery principles

No previous provincial-level awards received

Peer of the Year Category

 Peer support provider

 Uses, champions recovery principles

 Volunteerism

 Motivates others

 Appropriate story sharing

 May have received other awards

Pay it Forward Category

Public example of recovery

Has turned own life around

Has overcome significant challenges, including poverty

Pays it forward through Service to peers in mental health/addictions

Service above and beyond any assigned or paid role

4a) Why do you think your nominee is deserving of this award?

Please attach a description of the nominee’s activities or efforts relevant to this application, along with any supporting information. Your description should capture each of the activities you have checked above and can include more. Please ensure that the nominee is aware of your intention to nominate before you collect this information, and that the nominee signs the above declarations and initials every page that is sent to OPDI.

Please do not send the nominee’s entire resume or CV.

5. References - please provide contact information for the 2 primary reference letter providers and attach the reference letters with the application. Additional letters of supportfrom stakeholders are encouraged to increase your nominee’s chance of winning.

  1. Name:______
    E-Mail Address:______

Telephone Number:__(____)______or (_____)______

  1. Name:______
    E-Mail Address:______

Telephone Number:__(____)______or (_____)______

Nominator Signature: ______

Nomination form and all accompanying documentation must be
received bySeptember 2nd, 2016

Mail or courier to:

OPDI Awards Committee

720 Bathurst St @ Centre for Social Innovation Annex,

Toronto ON M5S 2R4

E-mail to:Fax to:416.484.9669

Incomplete applications or applications without the nominee’s signature and initials

cannot be considered.

The awarded nominee as well as their nominator will be notifiedSeptember 9th.

Please note: regular mail is slow and we prefer to receive nominations electronically. Please email your form and letters of support as attachments, or contact to arrange alternatives.