2013 Guidelines and Nomination Form
NominationForm

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Prime Minister's Awards for Excellence in Early Childhood Education
2013 Nomination Form

Please type or write in BLOCK letters. Please provide a separate form for each nominee.

Nominee's Personal Information

□ Dr. □ Mr. □ Mrs. □ Ms.

First Name __________________________________ Last Name ___________________________________

(Please provide names as they should appear on certificates.)

Home Address _____________________________________________________________________________

City/Community ____________________________ Prov./Terr. ____________ Postal Code _____________

Telephone (H) (____) ________________________ Email (H) ______________________________________

Telephone (W) (____) _______________________ Email (W) ______________________________________

Is the nominee a Canadian citizen or permanent resident?

□ Yes □ No

Does the nominee work a minimum of 2.5 days per week providing direct education and care to young children?

□ Yes □ No

Is this a team nomination?

□ Yes □ No

Does the nominee self-identify as Aboriginal?

□ Yes □ No

Personal Information

All personal information collected in nominations is protected under the Privacy Act. It is used by Industry Canada to process the nominations and for related statistical studies. Participation is voluntary. Information will be stored in Personal Information Bank IC PPU 001. Nominees may access, request correction of, or have a notation attached to the information about them at the address in the Nomination Guidelines. Each award recipient's name, early childhood education setting, community, and work contact information are included in short biographies published for the media and online at www.pma.gc.ca. Award recipients' photographs may also be used in promotional and information materials by the Prime Minister's Awards for Excellence in Early Childhood Education.

Nominator

To be completed by either an individual nominator or a representative of a nominating group.

□ Dr. □ Mr. □ Mrs. □ Ms.

First Name __________________________________ Last Name ___________________________________

Organization Represented (when applicable) ____________________________________________________

Address __________________________________________________________________________________

City/Community ____________________________ Prov./Terr. ____________ Postal Code _____________

Telephone (H) (____) __________________________ Telephone (W) (____) __________________________

Email (H)____________________________________ Email (W)_____________________________________

Supervisor/Guarantor

(Should a supervisor not be applicable, endorsement of a "guarantor" is requested, e.g. pastor, lawyer, community leader, MLA, etc. who has known you personally for at least two years.)

□ Supervisor □ Guarantor

□ Dr. □ Mr. □ Mrs. □ Ms.

First Name __________________________________ Last Name ___________________________________

Telephone (H) (____) __________________________ Tel. (W) (____) _______________________________

Email _______________________________________ 

Nominee's ECE Setting Information

Name of setting ____________________________________________________________________________

(Cash awards will be shared with this institution if the nominee is chosen for a Certificate of Excellence.)

Address __________________________________________________________________________________

City/Community ____________________________ Prov./Terr. ____________ Postal Code _____________

Telephone _________________________________ Fax __________________________________________

Email address  _______________________________________________________________________

(when applicable)

Website __________________________________________________________________________________

Type of Setting _____________________________________________________________________________

(e.g. child care centre, Aboriginal Head Start program, family child care program)

Ages of children in nominee's care _____________________________________________________________

Signatures

Nominator

Signature of Nominator ________________________________________ Date ________________________

Nominee

I, the nominee, affirm that all information contained in this nomination package is, to the best of my knowledge, complete and correct. I affirm that my license to operate, if applicable and certificate/diploma in Early Childhood Education and/or ECE credential is valid and in good standing. By signing this form, I authorize the Prime Minister's Awards office to conduct a verification of the information provided in this nomination. I also understand that award-winning ideas and methods will be published in an on-line exemplary practices publication and I give my release for that purpose. I have also read the Prime Minister's Awards recipient Code of Conduct found on the program website.

Signature of Nominee _________________________________________ Date ________________________

Supervisor/Guarantor

By signing this form, I, the Supervisor/Guarantor support this nomination.

Signature of Supervisor _______________________________________ Date ________________________

(or guarantor)

For more information or assistance in completing your nomination, please call the PMA office at 613-946-0651, or send us an Email to pmaece-ppmepe@gc.ca.

For PMA Office Use Only

Is evidence of the nominee's training in early childhood education and care included in the nomination package?

□ Yes □ No

Is evidence that the early childhood setting in which the nominee works is licensed included in the nomination package?

□ Yes □ No

Does the nominee have at least three years experience in a licensed early childhood setting?

□ Yes □ No

Does the nominee work a minimum of 2.5 days per week in a licensed early childhood education setting?

□ Yes □ No

Is the nomination text included in the nomination package?

□ Yes □ No

Are the three letters of support included in the nomination package?

□ Yes □ No

Does the nominee meet all criteria to be eligible for a PMA?

□ Yes □ No

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