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Athletes with Disabilities Hall of Fame
2012 Official Nomination Form


Nominations open January 13, 2012 and close May 31, 2012

Please complete this form in its entirety or download a Nomination Form PDF. To be considered, the official nomination form should be accompanied by the following:

  • Current photo of the nominee
  • Detailed summary of their athletic and community involvement
  • Minimum of two letters of recommendation.

Attach additional sheets, as necessary. We also encourage supporting documentation about the nominee such as media coverage, articles, certificates, athletic photographs, etc.
NOMINATION FOR*:
National Hall of Fame
Michigan Hall of Fame
Tony Filippis, Sr. Corporate Leadership
Rick Knas Lifetime Achievement
Pat Mcdonald Female Athlete of the Year
Roger Mccarville Male Athlete of the Year
Mark "Doc" Andrews Rising Star
ABOUT YOU:
*Nominator's name:
*Street Address:
*City:
*State:
*Zip Code:
*Telephone:
 (XXX) XXX-XXXX
Fax:
 (XXX) XXX-XXXX
*Email:
I heard about ADHOF Nominations from (check all that apply): Hall of Fame Website
Extremity Games Website
Hall of Fame Alumni
Hall of Fame Brochure
Social Media Site
Other... Please fill in:
ABOUT YOUR NOMINEE:
*Name of Nominee: 
Street Address:
City:
State:
Zip Code:
Phone:
 (XXX) XXX-XXXX
Email:
Date of Birth: 
 / / (MM / DD / YYYY)
Gender:
 FEMALE        MALE
Hometown City:
Hometown State:
Place of Birth City:
Place of Birth State:
TYPE OF DISABILITY*:
Amputation/Limb Loss

Cerebral Palsy

Developmentally Disabled

Dwarfism

Hearing Impaired

Muscular Dystrophy

Multiple Sclerosis

Spinal Cord Injury

Traumatic Brain Injury

Visually Impaired

Other (please specify):



CAUSE OF DISABILITY

Congenital/Birth Defect

Traumatic Injury

Infection/Disease Related

Other (please specify):

Please Explain:


NARRATIVE BIOGRAPHY OF NOMINEE - no more than 800 words
ADAPTIVE SPORT(S) IN WHICH THE NOMINEE PARTICIPATES / PARTICIPATED:
LIST SPECIFIC ATHLETIC EVENTS AND RANKINGS IN WHICH THE NOMINEE COMPETED:
Year Name of Competition Sport/Event Result
LIST AWARDS, HONORS, RECORDS, AND OTHER SPECIAL ATHLETIC ACHIEVEMENTS:
Year Recognition
LIST COMMUNITY INVOLVEMENT AND/OR PROFILE AS A POSITIVE ROLE MODEL:


OTHER NOTES OF INTEREST ABOUT THE NOMINEE:




Please attach supporting document: 1.       
Note: Please keep attached file less than 1 MB, since it will be emailed.               
 

Supporting documents may be delivered in any of the following ways:

  • Postal mail to the following address:
      Hall of Fame Nominations
      Athletes with Disabilities Network
      2845 Crooks Road
      Rochester Hills, MI 48309

  • Hand-deliver to the address above.

  • Email to info@adnpage.org

Questions? Contact Beth Geno Taylor, Executive Director
at btaylor@adnpage.org or call 248.829.8353.