Builder Nomination Form

Builder Nomination

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Part A - Nominee Information

First Name(Required)

Middle Name

Last Name(Required)

Mailing Address(Required)

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

Phone (Primary)(Required)

Phone (Secondary)

Email(Required)

Date of Birth(Required)

Place of Birth(Required)

Number of years residing within Lac La Biche County(Required)

If Deceased: Date of Death

Next of Kin Name (if applicable)

Next of Kin Mailing Address (if applicable)

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

Next of Kin Phone (Primary)

Next of Kin Phone (Secondary)

Nominator Information

Nominator Name(Required)

Relationship to Nominee(Required)

Phone (Primary)(Required)

Phone (Secondary)

Email(Required)

Date of Nomination(Required)

Part B - Accomplishments as a Builder

Nominated for involvement in the following sport(s) and/or community development for sport:(Required)

Please list details of the nominee’s accomplishments in the capacity of a builder of sport in Lac La Biche County. Include organizations and roles held, terms of roles, projects and/or initiatives the nominee initiated or was involved with, etc:

Organization / Club

Role(s) Held

Years of Service

Details of Involvement / Achievements

If the nominee was a coach or team manager, complete the following.

Please select (+) to add each sport, type of competition, role held (if different roles were held).

Role(s) (if coach or team manager)

International Level: (Olympics, Worlds, International meets)

Sport / Team

Dates

Age Level / Competition

Location

# of Teams

Status / Result

Role

National Level:

Sport / Team

Dates

Age Level / Competition

Location

# of Teams

Status / Result

Role

Western Canada:

Sport / Team

Dates

Age Level / Competition

Location

# of Teams

Status / Result

Role

Provincial Level:

Sport / Team

Dates

Age Level / Competition

Location

# of Teams

Status / Result

Role

Local / Regional Level:

Sport / Team

Dates

Age Level / Competition

Location

# of Teams

Status / Result

Role

List awards and honors bestowed upon the nominee during their career/volunteer commitments.

Honor / Award Received

Date Received

Issued By (List Organization)

Character & Community Connection

Please describe the nominee’s demonstrated character, their involvement and their connection in the community with respect to sport which has brought credit and high respect for the individual as well as the positive impact(s) they have made on sport in Lac La Biche County.

Additional Supporting Documents

Drop files here or

Max. file size: 50 MB.

Additional Supporting Documents, certifications, awards, clippings, letters of reference, etc.

Closing - Storyboard Bio & Photo of Athlete/Builder

Storyboard Bio (500 words or less)(Required)

In the space provided, in 500 words or less summarize the Athlete/Nominee’s introduction for their storyboard which is displayed as part of the Lac La Biche County Sports Hall of Fame. Highlight key accomplishments, awards, and chain of events in chronological order with dates which led to their overall success during their athletic career and speaks to their character. *Lac La Biche County may edit text for grammar, length and consistency to create personal story and will send final for review for approval prior to production.

Photo(Required)

Accepted file types: jpg, tiff, png, webp, Max. file size: 50 MB.

High resolution digital photo (1200 x 900 dpi) JPG or TIFF files preferred.

Consent(Required)

I consent to this nomination being submitted for the Lac La Biche County Sports Hall of Fame. I confirm the information provided is true and correct and allow the nominee's name and photo to be published in connection with the Hall of Fame.