Peace Medal Nomination Form - YMCA Northumberland

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Medallion Category

Peacemaker Nominee Information

Group/Nominee Full Name*

Nominee/Group Contact Email*

Nominee/Contact Phone*

Preferred Form of Contact*

Phone

Email

Professional References

Please provide the name and contact information for three professional references.

Professional Reference 1

First Last

Phone

Email

Professional Reference 2

First Last

Phone

Email

Professional Reference 3

First Last

Phone

Email

Peace Medal Information

Provide a brief history of the individual, organization or group*

How has the nominee inspired you and others through their acts of peace?*

How does the nominee demonstrate the YMCA values of PEACE?*

What is the impact of the nominee’s peacemaking work on the local, national, or global community?*

Describe any collaboration between the nominee and other groups and individuals.*

Social Media Information

LinkedIn Profile (if applicable)

Instagram Profile (if applicable)

Facebook Profile (if applicable)

Other Profile (if applicable)

Nominator Information

Nominator Name*

First Last

Nominator Email*

Nominator Phone*

Nominator relationship to nominee*

Memberships

Fitness

Aquatics

Peace Medal Online Nomination Form

Peacemaker Nominee Information

Professional References

Peace Medal Information

Social Media Information

Nominator Information

Useful Links

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