LifeStream Golden Hoosier Award Nomination

Guidelines

1. Nominee must be age 65 years or older on or before January 1, 2022.
2. Must have positively impacted members of a community, civic organization, or faith-basedorganization through volunteer efforts at least three years after reaching 60 years of age.
3. Nominee must be a resident of Indiana and reside in Blackford, Delaware, Fayette, Franklin, Henry, Jay, Madison, Randolph, Rush, Union, or Wayne county.
4. Previous recipients of the LifeStream Golden Hoosier Award are not eligible.
5. This form must be completed to qualify the nominee for the award. Additional sheets may be attached if needed.
6. A selection committee representing LifeStream Services will select the top 50 nominees and the LifeStream Golden Hoosier Award recipients.
7. The selection committee will also nominate individuals for special recognition by the Indiana Lieutenant Governor and Indiana Family and Social Services Administration.

Nominee Information

Nominee Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Nominee Date of Birth(Required)

Phone(Required)

Reason for Nomination(Required)

Please provide a detailed explanation.

Nominator Information

Nominated By:(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

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LifeStream Golden Hoosier Award Nomination

Guidelines

Nominee Information

Nominator Information

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