MDSC Media Award Nomination Form

Your Information:

First Name Last Name

Street Address

City State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code

Email Address Phone Number

Nominee's Information:

First Name Last Name

Street Address

City State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code

Email Address Phone Number

Nominating letters should include specific examples rather than general statements about the person or company.  Please submit a letter of nomination, not to exceed two pages, answering the following questions:   

• Please describe the advertisement, media message, news article, or television program.
• What positive message about Down syndrome did the media convey?
• When, where, and for how long was this message conveyed?
• Who was the target audience for this media message?

Attach Nomination Letter

= Required