Healthcare Georgia Foundation

Collaborative Nomination Form ^* Indicates a required field

One collaborative (comprised of three or more health-related Georgia nonprofit organizations) will be selected for this award. In order 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].

Collaborative nominees must:

Be actively working together
Represent partnership models working towards promising practices and results
Show initiative and a deep commitment to addressing health-related needs of the community
Demonstrate that the collaborative effort has been effective in improving the health of a Georgia community
Reflect diversity in its membership

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

Collaborative Award Criteria

*Provide a detailed history and description of the collaborative effort. Include goals, and objectives.

*Describe the roles and responsibilities of the organizations involved in the collaborative.

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

*What impact has the collaborative had on the community? Be sure to include successes and specific results.

*Does this organization reflect and represent the diversity of the community it serves?

*Describe how the collaborative has been proactive in initiating change to promote better health outcomes in the community it serves.

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

Collaborative Nomination Form * Indicates a required field

Collaborative nominees must:

For Low Vision Users

Collaborative Nomination Form ^* Indicates a required field