Healthcare Georgia Foundation

Individual Nomination Form ^* Indicates a required field

Five individuals will be selected for the award. To be considered for the award, the following requirements must be met.
A list of previous recipients can be found here.

For assistance with this form, please email [email protected].

Five individuals will be selected for the award. To be considered for the award, the following requirements must be met.

Individual nominees must:

Be a volunteer or a previous volunteer for a health-related, nonprofit organization
Have made a passionate commitment to improving the quality of health in a Georgia community
Have unselfishly contributed their time to community activities
Serve as a role model and inspiration to others

Nominee Information

*Name:

*Volunteer Organization Name(s)

*Address

*City

*State

*Zip

*Telephone

Fax

*Email

Ethnicity

Gender
Male Female

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

*1. What service does the nominee provide to the community and/or organization for which they volunteer? Please include the population served and the approximate number of hours per month served by the volunteer in this capacity.

*2. Has the volunteer ever been paid to fill this role? Refer only to the nominee's role as a volunteer.

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

*4. What achievements, if any, can be cited as the direct result of this nominee's volunteer service to the community? Include specific, measurable outcomes, if applicable (e.g. improved health services, increased access to care, cost reductions, and improved community engagement with health and wellness activities) .

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

*6. What motivated you to nominate this individual?

Attachments:
Please email any attachments that you would like to include with your submission to [email protected].

*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.

Healthcare Georgia Foundation

Individual Nomination Form * Indicates a required field

Individual nominees must:

For Low Vision Users

Individual Nomination Form ^* Indicates a required field