Champions for Better Health

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Nominee

Name of Nominee: *

Title: *

Address: *

Phone: *

Email: *

Nominator:

Nominator's Name: *

Title: *

Address: *

Phone: *

Email: *

Summary of Major Contributions: How have this organization's or individual's accomplishments been outstanding in advancing the health of our community?

*

As a result, how has our community and the population benefited in the areas of: 1) improved access to affordable health care and/or; 2) promotion of healthy lifestyles?

*

Optional

Please use this section if you feel additional support is necessary.

Letters of Recommendation:

Please submit a letter of recommendation with this application. Email it to Ann Myers at Ann@ForBetterHealthPA.org.

Photo:

Optional - Send a photo of the individual and/or their organization’s work in the community to Ann Myers.

References:

Please share contact information for one reference who can speak to the nominee’s accomplishments.

Reference:

Name: *

Relationship to the Nominee: *

Phone: *

Email Address: *

Applications are due by April 3, 2017

Address questions to: Ann Myers, Chief Gift Planning Officer, at Ann@forbetterHealthPA.org