Mental Health Champions Nominations

Each year an award recipient is selected from each of the three nomination categories: mental illness, developmental disabilities, and substance use disorders. They are celebrated at the annual Mental Health Champions’ Awards Banquet held in their honor. This year, the event will be on May 7, 2024, at the Capitol Plaza Hotel in Jefferson City.

If you have any questions regarding the Mental Health Champions Award, please contact the Missouri Mental Health Foundation at (573) 635-9201 or mmhf@missourimhf.org. If you prefer to submit via mail, use this PDF version of the nomination form.

Persons may be nominated in one of three categories:

An individual with a diagnosed mental illness
An individual with a developmental disability
An individual in recovery from a substance or gambling addiction

Nomination Application

Nominees must agree to allow their stories to be told.
Those who nominate eventual winners may be asked to appear in a video tribute for that individual, along with others who have witnessed or who may benefit from the winner’s noted accomplishments.
Please include a picture – in JPG or PNG format – of each nominee. Their picture will be put in the keepsake program booklet that will be distributed the night of the event. This picture does not need to be a professional headshot.

Mental Health Champion Nominations

"*" indicates required fields

NOMINEE INFORMATION

Nominee's Name:*

Organization Nominee Affiliated With (if any):

Category Nominating In:*

Individual with a Diagnosed Mental Illness

Individual with an Intellectual/Developmental Disability

Individual in Recovery from a Substance or Gambling Disorder

Choose one (1) category to nominate the candidate in.

Nominee's Complete Address*

Email Address of Nominee

Telephone Number Where Nominee May Be Reached*

INFORMATION OF PERSON SUBMITTING THE NOMINATION

Name Of Person Submitting Nomination:*

Organization Nominating Person Affiliated With (If Any):

Address of Person Submitting Nomination:*

Email Address of Person Submitting Nomination*

Telephone Number That Nominating Person Can Be Reached At:*

NOMINEE VERIFICATION

Please provide two references to verify the scope and extent of the nominee’s activities. References should be familiar with the nominee’s achievements, but not a family member of the nominee. The nominator does NOT count as a reference.

Reference #1

Reference Name:*

Organization Affiliated With (If Any):

Reference's Complete Address*

Reference's Telephone Number:*

Reference's Email:

Reference #2

Reference Name:*

Organization Affiliated With (if any):

Reference's Complete Address*

Reference's Telephone Number:*

Reference's Email:

QUESTIONS ABOUT NOMINEE

1. Describe how the nominee exemplifies courage, commitment, and success in their community or their personal development. Include examples of circumstances and challenges the nominee has faced in their life, and how they have been able to address and/or overcome many of their challenges.*

2. In what way does the nominee serve as an inspiration to others? Please provide specific examples of positive contributions to their community, state, and/or across the nation and how this nominee has helped to improve the lives of others or enhance access and inclusion for people with disabilities and/or mental health conditions.*

3. Describe the nominee’s ability to participate in planning, organizing, and/or developing ideas or projects, including working cooperatively with others. Please provide specific examples of initiatives and actions that have helped increase the independence of individuals with similar intellectual and developmental disabilities or mental health conditions.*

4. Describe how the nominee provides information about skills related to health, wellness, and/or recovery to individuals and their community. Describe how they demonstrate collaboration, teamwork, leadership, and/or advocacy.*

5. What, do you believe, is the nominee’s goal to enhance their own life and the lives of others with intellectual and developmental disabilities or a mental health condition? Describe the person’s efforts; how they enhanced access and inclusion through advocacy, their involvement, and/or sharing their story. Note how their actions improved the lives of others.*

6. Other comments/information regarding the nominee.

Please upload a photo of the nominee in a jpg or png format.

Accepted file types: jpg, png, jpeg, Max. file size: 8 MB.

We strongly encourage you to send a headshot now; it must be submitted at some point in the process. If you don’t upload one now, we’ll reach out.

Please Note: All nominees must sign a release form granting the Missouri Mental Health Foundation unlimited permission to use, film and publish their likenesses, as well as information about them.