Individual nomination form

Nominator Address *

Nominee Information

Contact information for the woman or group that you are nominating
Nominee Name *

First Name Last Name
Nominee Email *
example@example.com
Nominee Phone Number *

Area Code Phone Number

Nominee Address

Nomination

Please ensure that the woman or group you are nominating is aware that this information is being shared.
Nomination Summary *
Provide a short paragraph about your nominee (which we may use for publicity purposes)
Are travel expenses required? *

No Yes
Are you able to sponsor travel expenses for your nominee?

No Yes
Raising Awareness
What has the nominee done to raise awareness of violence against women and how has she tried to bring about change? This can be through writing or campaigning.
Challenges
How has she tried to overcome obstacles or challenges to this work?
Innovation
What has the nominee done that's really outstanding, innovative and original?
Above and Beyond
Has the nominee done this work as part of her paid work? If so, can you show that she has gone further than she needed to do for her job, or has done this work in addition to her paid job?
Impact of the award
What difference will this award make to her work?
Other relevant information
Any other relevant information
Should be Empty:

Emma Humphreys Memorial Prize nomination form