Multiple Sclerosis Society of Canada

Multiple Sclerosis Society of Canada Atlantic Division PRESIDENT’S AWARD

The purpose of the President’s Award is to recognize the valuable contributions of persons with MS within the MS Society of Canada. The criteria for this award are based on the objectives of the James D. Wolfensohn Award of the Multiple Sclerosis International Federation (MSIF):

1. The candidate has enhanced the influence and position of persons with MS within the MS Society of Canada.

2. The candidate has created greater public awareness of the importance of active involvement of persons with MS.

The winner of the Divisional President's Award may become the Division’s nominee for the National President’s Award. The National recipient of the President’s Award will become the MS Society of Canada’s nominee for the MSIF’s James D. Wolfensohn Award. Please note that to win the National President’s Award, a nation-wide scope of service must be demonstrated. This is defined as impacting two or more divisions.

Who may nominate: Nominations can be made by members and/or staff of the MS Society of Canada, and submitted to the nearest division office. Each division then selects their division President’s Award recipient from among the submissions, and that individual becomes their nominee to the national President’s Award. The national office may also submit a nomination to this award.

AWARD CRITERIA

 Individual has MS  Involvement in and contribution to the development/growth of the MS Society  Enhanced the influence of persons with MS with the Society through their own activities  Impact felt within the Society and in the community-at-large

The deadline for nominations is November 30.

Please forward nominations to: MS Society of Canada, Atlantic Division 109 Ilsley Avenue, Unit 1 Dartmouth, NS B3B 1S8

The recipient will be presented with a plaque honouring his/her contribution as a member to the work of the Multiple Sclerosis Society of Canada. Multiple Sclerosis Society of Canada Atlantic Division PRESIDENT’S AWARD DIVISION INFORMATION

DIVISION

CONTACT NAME

EMAIL Multiple Sclerosis Society of Canada Atlantic Division PRESIDENT’S AWARD NOMINEE INFORMATION

DATE OF BIRTH (MM-DD-YYY)

ADDRESS

CITY, PROV, POSTAL CODE

PHONE and EMAIL DATE OF MS DIAGNOSIS

NOMINATOR INFORMATION

NAME PHONE NUMBER

CHAPTER/COMMITTE EMAIL E

The following information should be submitted.

1. Describe nominee’s past and present MS symptoms. (i.e. date of diagnosis, symptoms)

2. Describe nominee’s past and present initiatives and endeavors (Leadership qualities, resourcefulness, perseverance, adaptability, compassion, tolerance and membership/affiliations)

(a) Personal (self / family, etc.)

(b) Community (other persons/groups)

(b) MS Society or group Multiple Sclerosis Society of Canada Atlantic Division PRESIDENT’S AWARD

3. Describe nominee’s past and present other volunteer work and achievements. (outcomes, benefits, distinctions/awards) Provide a brief summary on how these endeavors affect people living with MS.

4. List nominee’s major activities chronologically, beginning with the most recent activity (state dates and whether activity was volunteer, full-time employment or part time employment,)

5. Additional comments (eg. economic need, etc.) Multiple Sclerosis Society of Canada Atlantic Division PRESIDENT’S AWARD PRIVACY STATEMENT / RELEASE OF INFORMATION

The MS Society of Canada collects the personal information requested on the award nomination forms for the purpose of recognizing the achievements and contributions of individuals and groups in support of our mission statement. By completing the release of information section on the nomination form you hereby consent to the collection, use and disclosure by the MS Society of your personal information and/or image in accordance with the MS Society privacy policy. Disclosure of personal information and/or images may include, but is not limited to, committees, members, and the general public via public presentation, print materials, media releases and our website. A copy of our privacy policy may be obtained at www.mssociety.ca or by calling 1-800-268- 7582.

I, ______hereby give my permission to the Multiple Sclerosis Society of Canada to release pertinent personal information and/or my image for the purpose of this nomination.

Furthermore, I agree to serve as the focus for publicity regarding the commitment and work of persons with MS within the MS Society of Canada and to allow my name to be submitted as a nominee for the Multiple Sclerosis International Federation’s James D. Wolfensohn Award.

SIGNATURE ______

DATED AT______, IN THE PROVINCE OF______,

THIS _____ DAY OF ______IN THE YEAR ______.