Faith in Action Award Consent Form

The Honourable Mayann Francis Faith in Action Award Consent Form
The Honourable Mayann Francis Faith in Action Award, presented by Atlantic School of Theology, honours exceptional community outreach that is recognized as having provided significant benefit to the wider community.

Please fill out this consent form.

Note: The nominee or official organization representative must sign to be considered.
Nominee's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In signing below, I certify that I agree to let my name or group’s name stand for the nomination. I consent to releasing the information included in this nomination to the Award Selection Committee and the media for news releases and articles. I also consent to releasing my phone number to be contacted by the media for interviews about the recipient of the Honourable Mayann Francis Faith in Action Award and, if selected for an award, for photos taken at the ceremony.
Signature
Should be Empty:

The Honourable Mayann Francis Faith in Action Award Consent Form