Ben Yorgey Memorial Award Nomination Form The registration deadline is March 24, 2023. To download a copy to print, click here. 2023 Ben Yorgey Memorial Award Nomination Nominee DetailsName* First Last Age*City* Zip* School District of Residence* Classroom Location/Teacher* School Phone*List any agencies the student is currently receiving services through* Is the nominee involved with OVR?* Yes No Nominee Family Contact DataFamily Contact Name* First Last Family Contact Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Phone*Preferred Email* Please upload a recent picture of the nominee.Max. file size: 300 MB.Nominator DetailsYour Name* First Last Your Email* I am:* An Educator A Parent A Community Member Initials of Nominator* Nominator Title Nominator Phone*Nominee Details*
