Perth Medal Nomination - Town of Perth

Required fields are marked with asterisks (*)

Thank you for submitting a nomination for the Perth Medal!

The Perth Medal is a Mayor’s Award, presented annually by the Town of Perth to a person who has shown the greatest distinction in a number of endeavours, over the course of his or her life, to benefit the Perth community as a whole, with no monetary gain to themselves. This may be in the fields of community work, fundraising, volunteerism, etc.

A nominee must be an individual (no couples or groups) who resides in the Town of Perth or the surrounding Townships of Tay Valley or Drummond/North Elmsley. The activity being recognized must be totally and singularly related to achievements within the Town of Perth. No person elected to public office may be nominated, nor may the award be presented posthumously.

Nominations must be submitted through this form, or you can request a copy by email from Karen Szabo or by phone at 613-267-3311 Ext. 2279. Submissions must be received no later than 4 p.m. on Friday, June 6, 2025.

Note: all personal information contained on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and will only be used for the purpose of assessing the nominees and awarding The Perth Medal.

General Information

Please enter your First Name

Please enter your Last Name

Please enter your Phone Number

Please enter your Email Address

Please enter the nominee's First Name

Please enter the nominee's Last Name

Please enter the nominee's Phone Number

Please enter the nominee's Email Address

Please enter the nominee's address including street, town and postal code.

Is the nominee a resident of the Town of Perth, Tay Valley Township, or Drummond/North Elmsley Township, and are not currently an elected member of a local municipal government?

Yes

Section 1 - Volunteer Years of Service – Maximum of 20 Points

Please indicate how many years the nominee has been actively serving in the Town of Perth as a volunteer:

Less than one year (1 point)

1 up to 5 years (2 points)

5 up to 10 years (8 points)

10 up to 15 years (12 points)

15 up to 20 years (16 points)

20 years or more (20 points)

Section 2 - Quality of Life Impact to the Town of Perth and Community – Maximum of 20 Points

Category	Minimal Impact (5 points)	Medium Impact (10 points)	Considerable Impact (20 points)
No of Sectors Impacted	1-2 Sectors	3-5 Sectors	6 or more Sectors

Has the Nominee has contributed to Recreation/Sport in the Town of Perth and community?

Yes

If the nominee has contributed to Recreation/Sport, please describe how:

Has the Nominee has contributed to Heritage/Cultural in the Town of Perth and community?

Yes

If the nominee has contributed to Heritage/Cultural , please describe how:

Has the Nominee has contributed to Youth at Risk Support in the Town of Perth and community?

Yes

If the nominee has contributed to Youth at Risk Support , please describe how:

Has the Nominee has contributed to Tourism/Events in the Town of Perth and community?

Yes

If the nominee has contributed to Tourism/Events, please describe how:

Has the Nominee has contributed to Health Care/Services in the Town of Perth and community?

Yes

If the nominee has contributed to Health Care/Services, please describe how:

Has the Nominee has contributed to Supporting Low Income in the Town of Perth and community?

Yes

If the nominee has contributed to Supporting Low Income , please describe how:

Has the Nominee has contributed to Education in the Town of Perth and community?

Yes

If the nominee has contributed to Education, please describe how:

Has the Nominee has contributed to Economy in the Town of Perth and community?

Yes

If the nominee has contributed to Economy, please describe how:

Please describe any additional way the nominee has contributed to the quality of life in the town of Perth.

Section 3 - Describe the Rationale for the Award – Maximum of 30 Points

Category	Minimal Impact (2 points)	Medium Impact (5 points)	Considerable Impact (10 points)
Population Impacted	50 persons or Less	100 + persons	1000+ persons
$ Value of Impact (in cash or in Kind)	Minimal ($100 or less)	Medium ($1000+)	Considerable ($5000+)
Duration of Impact	Short-lived (less than 1 year)	Moderate (between 3-5 Years)	Long term benefit (greater than 10 Years)

Please provide a profile and background information about the individual nominated identifying the nominee’s contributions or service worthy of notice. Include the approx # of people Impacted, $ Value of Impact, and the duration of their impact

Section 4 - References – Maximum 5 Points

Please provide two (2) References that can affirm the Nominee’s achievements.

Please enter Reference #1 First Name

Please enter Reference #1 Last Name

Please enter Reference #1 Phone Number

Please enter Reference #1 Email Address

Please upload a letter of support from Reference #1

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Please enter Reference #2 First Name

Please enter Reference #2 Last Name

Please enter Reference #2 Phone Number

Please enter Reference #2 Email Address

Please upload a letter of support from Reference #2

Browse…

Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Nominee Confirmation

Have you confirmed with the nominee that they are willing to have their name stand for this award?

Yes

Submission Confirmation

By submitting this Nomination Form, I confirm the facts set forth in it are true and complete

Yes

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