Healthcare Georgia Foundation

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Community Service

Individual Nomination Form

Nominee Information

Name: *

Volunteer Organization Name(s) *

Address *

City *

State *

Zip *

Telephone *

Fax

Email *

Alternate address

Address

City

State

Zip

Telephone

Fax

Email

Nominator Information

Name: *

Title

Volunteer Organization Name(s) *

Address *

City *

State *

Zip *

Telephone *

Fax

Email *

Alternate address

Address

City

State

Zip

Telephone

Fax

Email

Individual Award Criteria

Provide a detailed description of the nominee's involvement as a volunteer in the community.*

How would you describe the nominee's commitment to addressing the health needs in their community?*

What projects related to health and/or health care concerns does this collaborative address?*

Would you consider this nominee a role model or community leader? If so, why?*

As a volunteer, what impact do you believe the nominee has had on the health of the community they serve?*

What motivated you to nominate this individual?*

Your (Printed) Name *

Date *

Electronic Signature Confirmation *

Once you press submit, this form cannot be revised. Upon submission, you will receive an email confirmation of your nomination.

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