2013 Caregiver of the Year – Nomination Form

Name of Caregiver:
__________________________________________________

Address of Caregiver:
__________________________________________________
__________________________________________________

Phone Number of Caregiver:
__________________________________________________

E-mail Address of Caregiver:
__________________________________________________

Name of Nominator:
__________________________________________________

Address of Nominator:
__________________________________________________
__________________________________________________

Phone Number of Nominator:
__________________________________________________

E-mail Address of Nominator:
__________________________________________________

Attach the following materials to this application:

1.  Describe the needs of the senior and provide examples of the
     extraordinary actions of the caregiver. 
     You may also submit photos.

2.  Sign the attached Certification.

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Application deadline:  All materials must be submitted by mail or e-mail before April 1, 2013.

Mail application to:
Caregiver of the Year Award
c/o Cona Elder Law PLLC
225 Broadhollow Road, Suite 200
Melville, New York 11747
Attention: Moriah Farrell

OR e-mail to: elder@conalaw.com (please indicate Caregiver of the Year in the subject line.)

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2013 Caregiver of the Year Award Certification

I hereby certify that all of the statements contained and information provided in this application, and in the attachments hereto, are truthful, to the best of my knowledge.

I hereby grant permission for my name, photo and story to be included in any reputable media including newspaper, magazine, TV, radio as well as posted on the Cona Elder Law website.  In addition, if requested, I agree to be interviewed by print and broadcast media.    

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Applicant’s Signature

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Date