SOC/HTEP Grant Champion Nomination

"*" indicates required fields

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Training Title*

SOC/HTEP Beyond the Grant Sustainability Planning Session

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Date/Time Selection

June 22-23, 2023 (8:00 AM - 4:30 PM Thursday; 8:30 AM - 1:00 PM Friday)

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Waitlist Date/Time Selection*

Month Day, Year XX:XX-XX:XX MST

Your Name*

First Last

Your Email*

Enter Email Confirm Email

Your Phone Number*

Your Role/Title*

Your Agency/Organization*

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Organization Location/Service Area

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Participant Category

Other Participant Category*

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Sleeping Room Requested?

Check all that apply.

Wednesday Night, June 21, 2023

Thursday Night, June 22, 2023

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Dietary Restrictions or Preferences?

Including food allergies

Yes

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Describe Dietary Restrictions or Preferences

Champion Award Nomination

Recipients will be honored during the BEYOND THE GRANT Sustainability Planning Session

Nomination Category*

Select All That Apply. Active Youth Related Participant examples, could include but are not limited to, Youth Peer Support Worker, Youth Trainer, Youth Advisory Participant, or Youth Move Member.

Family Peer Support Worker

NM High-Fidelity Wraparound Facilitator

Active Youth Related Participant

Do not wish to submit a nominee

Family Peer Support Worker

For each area below please describe, using specific examples that will illustrate your nominee’s distinctive qualities, why you think your candidate deserves to be a SOC/HTEP Champion behalf of the children, youth, and families of New Mexico. *Note: if an area below is not relevant or does not apply to your nominee, please enter “N/A” or leave it blank.

Nominee Position*

This field is necessary in the case where you may have elected to nominate in multiple categories.

Family Peer Support Work

NM High-Fidelity Wraparound Facilitator

Nominee Name

First Last

Nominee Email

Enter Email Confirm Email

Nominee Phone

Nominee Agency/Organization*

Empathy, Engagement, Advocacy, Knowledge

Describe a specific time or times when your nominee demonstrated Empathy, Engagement, Advocacy, or Knowledge for the children, youth, families, and other community partners with whom they serve.

Professionalism, Relationships, Leadership, Collaboration

Tell us about a time the nominee demonstrated Professionalism, Relationships, Leadership, or Collaboration with the children, youth, and families with whom they serve.

Anything Else?

What else should we know about your nominee that has not yet been mentioned? Please do not summarize or echo above qualities.

NM HIgh-Fidelity Wraparound Facilitator

Nominee Position*

This field is necessary in the case where you may have elected to nominate in multiple categories.

Family Peer Support Work

NM High-Fidelity Wraparound Facilitator

Nominee Name

First Last

Nominee Email

Enter Email Confirm Email

Nominee Phone

Nominee Agency/Organization*

Empathy, Engagement, Advocacy, Knowledge

Describe a specific time or times when your nominee demonstrated Empathy, Engagement, Advocacy, or Knowledge for the children, youth, families, and other community partners with whom they serve.

Professionalism, Relationships, Leadership, Collaboration

Tell us about a time the nominee demonstrated Professionalism, Relationships, Leadership, or Collaboration with the children, youth, and families with whom they serve.

Anything Else?

What else should we know about your nominee that has not yet been mentioned? Please do not summarize or echo above qualities.

Active Youth Related Participant

Nominee Position*

Youth Advisory Participant

Youth Move Member

Youth Peer Support Worker

Youth Trainer

Other

Nominee Position-Other

Nominee Name

First Last

Nominee Email

Enter Email Confirm Email

Nominee Phone

Nominee Agency/Organization*

Empathy, Engagement, Advocacy, Knowledge

Describe a specific time or times when your nominee demonstrated Empathy, Engagement, Advocacy, or Knowledge for the children, youth, families, and other community partners with whom they serve.

Professionalism, Relationships, Leadership, Collaboration

Tell us about a time the nominee demonstrated Professionalism, Relationships, Leadership, or Collaboration with the children, youth, and families with whom they serve.

Anything Else?

What else should we know about your nominee that has not yet been mentioned? Please do not summarize or echo above qualities.

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Champion Award Nomination

Family Peer Support Worker

NM HIgh-Fidelity Wraparound Facilitator

Active Youth Related Participant

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