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Nominate an Individual

Deadline Extended: Monday November 18, 2019

Submit a nomination by filling out the form below. Please note the nomination form cannot be saved and completed at a later date. Before you begin, please preview the Individual Nomination Form in its entirety to fully answer questions. It is recommended that the nominator complete questions in a word document and edit prior to filling out the below online nomination form.

If you have questions, please contact Lisa Medellin, Director of Programs at lmedellin@healthcaregeorgia.org or by phone (404) 653-0990.

    Name*
    Title*
    Organization*
    Address
    City
    State
    Zip Code
    Phone*
    Email*

    Name*
    Title*
    Organization*
    Organization Website
    Length of time nominee has volunteered at organization*
    Address
    City
    State
    Zip Code
    Phone*
    Email*
    Race/Ethnicity*

    Gender*

    1. What motivated you to nominate this individual?*

    2. What service(s) does the nominee provide to the community for which they volunteer? Please describe the community served by this volunteer’s efforts.*

    3. Has the volunteer previously been paid to fill this role?*
    (Only non-paid volunteer roles/positions will be accepted)
    YesNoDon't Know

    4. What specific achievements have occurred as a direct result of this nominee’s volunteer service to the community?*

    5. How has this volunteer affected improved health services, increased access to care, and/or improved engagement with health and wellness activities with the residents in the communities they serve?*

    6. Why do you consider this nominee a role model or community leader?*

    7. How has the nominee demonstrated a commitment to Health Equity?*


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