Culturally Significant Individual Nomination Form

SECTION 1: Nominee Information

1. Full Name of the Individual Being Nominated

2. Their Role or Title (if applicable)

(E.g., artist, educator, healer, youth leader, activist, storyteller, elder)

Individual Image

3. Location

(City, State)

If a secondary city is influenced, please enter it here.

(City, State)

4. Contact Info (email or social media, if known)

5. Briefly describe who this person is and what they do.

SECTION 2: Cultural Contribution Area

6. Which cultural impact area(s) best describe this person’s work?

Health, Wellness, and Education (Initiatives focused on health, holistic wellness and education)
Economic Opportunity and Equality (Individuals that empower, assemble and/or align with cultural integrity and community values)
Arts, Community, and Heritage (Creative expressions and heritage initiatives that define cultural identity)

SECTION 3: Cultural Significance

7. Briefly describe the mission and/or main activities that contribute to being culturally significant.

Note: This answer will be published to the public dashboard library and viewable by everyone as an explanation of why considered culturally significant. If you need guidance, please refer to the Cultural Significance Checklist.

8. How does their work serve or uplift a specific cultural, ethnic, or social group?

9. Is this person a part of the community they serve?

Yes
No
Not sure

10. How has this individual shown authentic leadership or representation within their cultural community?

(How do they preserve or promote cultural values, justice, or traditions?)

11. How do they foster inclusivity or bring different communities together?

SECTION 4: Community Impact

12. How many people do they regularly impact through their work?

A few individuals (1–10)
Small groups (10–50)
Dozens to hundreds
500+ (citywide or broader impact)

13. Describe how their work or presence has made a lasting impact on others.

(You can include examples, quotes, or stories if relevant.)

14. Does this person lead or participate in any local events, programs, or initiatives?

15. Has their work inspired new cultural practices, healing, or partnerships?

SECTION 5: Additional Notes (Optional)

16. Is there anything else we should know about the individual’s cultural importance or legacy?

Culture Dash

Culturally Significant Individual Nomination Form

Culture DASH

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