2023 Caregiver Submission Form

DEADLINE FOR SUBMISSION IS FRIDAY,OCTOBER 13, 2023.

Use this form to submit information about a caregiver you wish to recognize and to register the caregiver and yourself for the luncheon.

Tips on Recognizing a Caregiver(s)

Submit one form for each caregiver

1. Identify the caregiver you wish to recognize. Contact the caregiver to let them know you are submitting their name for recognition and find out if they can attend the event on Thursday, November 16th, 2023. If they are not able to attend, we can still recognize them. Be sure to get their personal contact information NOT their business/agency’s. There is no limit on the number of caregivers you may choose to honor, however each must be submitted on a separate form.

2. Select one of the categories below that BEST suits the caregiver you wish to honor. Please do not submit the same caregiver for multiple categories.

• Family Caregiver – Provides care for an adult in their own family who is at least 23 years old or older. Family caregivers need recognition when they provide extra support and care for a spouse/partner, parent, child, sibling, grandparent, or other extended family members.
• Family Caregiver for Child or Youth with Special Needs – Provides care in their own family for a person 22 years old or younger.
• Volunteer Caregiver – Provides voluntary support and/or a wide range of caregiving tasks for a person or persons of any age in their home who is NOT a family member. This may include friends, neighbors or others such as those who voluntarily support hospice patients, serve as companions, provide transportation or a myriad of other caregiving duties.
• In-Home Professional Caregiver – Is employed by a company or is self-employed by the family or care receiver to provide care for a person or persons of any age in their home. This includes home health workers such as nurses, aides, and therapists, personal care attendants, hospice staff, and respite workers.
• In-Facility Professional Caregiver – Is employed by a company to provide care for people of any age in a group setting such as adult day care, nursing homes, assisted living, hospitals or rehabilitation facilities.
• Dual Life Caregiver – Provides care for a person or persons of any age in addition to being employed elsewhere full time.
• Caregiver for a Veteran – Provides care for a person of any age who is a veteran. Care for the veteran does not need to be service-related.

3. Include $40 for each caregiver submission, and $40 for yourself if you plan to attend the luncheon. If you need financial assistance to submit a caregiver for recognition, we have scholarships available to help. Contact Marta Malone for details: 775-848-1260.

4. Before you begin, reach out to your caregiver and let them know you are recognizing them and ask if they can attend. Be sure to get their personal contact information-DO NOT use yours or your organization’s contact information for the caregiver.

We also recommend you have the following information readily available:

• Caregiver’s Contact Information (NOT yours or your agency’s)

• Narrative ready to copy and paste into online form (Narrative is 500 words Maximum with mention of which person, family or organization the caregiver is associated with.)

• 1-2 Photos of the Caregiver

• Logo of the Business/Agency honoring the Caregiver

• Debit/credit card for payment

Please be sure to complete all required fields throughout the process to streamline your experience.

AFTER SUBMITTING THE ONLINE FORM, WAIT TO BE REDIRECTED TO THE PAYPAL PORTAL TO COMPLETE YOUR PAYMENT.