2025 Distinguished Survivor Award Nomination Form

Distinguished Survivor: This award is given to a crime victim/ survivor or a family member of a victim that has persevered through adversity and tragedy.

Name of individual making nomination:

First Name

Last Name

Phone

(###)

###

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Email Address

Nominee's full name:

First Name

Last Name

Nominee's email:

Provide up to three characteristics and indicate why they best describe the nominee:

Briefly provide information regarding what the victim/survivor or a family member has done to persevere through adversity and tragedy as a result of the crime:

Did the victim/survivor or a family member overcome significant obstacles to provide unique services, or develop any programs for victims of crime?

If yes, describe the service or program:

Relationship with the nominee?

OPTIONAL: In 100 words or less, please summarize your reasons for nominating this individual:

2025 Distinguished Survivor Award Nomination Form

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