SOMERSET COUNTY OFFICE ON AGING AND DISABILITY SERVICES

SOMERSET COUNTY OFFICE ON AGING AND DISABILITY SERVICES “PROFILES OF POSITIVE AGING” Nomination Form In Recognition of OLDER AMERICANS MONTH 2016 National Theme: “BLAZE A TRAIL” In cooperation with the Federal Department of Health & Human Services’ Administration for Community Living

Nomination criteria: Somerset County residents age 60 and above who currently make contributions and set examples for others on ways to take charge of one’s health, get engaged in their communities and make a positive impact on the lives of others. Examples include leading self-help, health promotion activities; serving on community based health/safety focused committees; leading/assisting with consumer-protection related projects, etc. Nominees may not have been previously recognized for this award. This form must be received by April 8, 2016. The top ten nominees to be honored will be notified by phone and recognized by the Somerset County Board of Chosen Freeholders at the May 10, 2016 evening meeting. Nominee:

Date of Birth:

Address: Home Phone :(____) _________ Alternate :(____)

Email:

Name of Nominator: Organization /Agency/ or Relationship: Address: Home Phone :(____) _________ Alternate :(____)

Email:

Please describe the nominee’s involvement in each area below: Service in special initiatives related to safety and health that will benefit others: ____________________________________________________ Examples of embracing an active lifestyle:

Volunteerism in health/safety capacities over the last 12 months:

Describe how this person’s involvement in health/safety initiatives makes a positive impact in their community:

Mail to: Cynthia D. Voorhees, Eldercare Services Coordinator Somerset County Office on Aging and Disability Services P.O. Box 3000 Somerville, NJ 08876 Fax: (908) 704-6349 Email: [email protected] Sponsored by the Somerset County Office on Aging and Disability Services and the Somerset County Board of Chosen Freeholders