2017 Women's Champion Nomination Form

Deadline for Class of 2017: March 31st, 2017

Do you know someone who would be a great candidate as a Women’s Champion for the Alzheimer’s Association? Our Women’s Champions represent women from across the state who have made a commitment to make Alzheimer’s a priority in their lives, work, volunteerism and philanthropy moving us closer to a world without Alzheimer’s. Nominate a champion for the Class of 2017 today. You and your nominee will be notified in late spring of their acceptance into the Class of 2017. Questions? Contact Jennifer Walker at 860-828-2828 or jenwalker@alz.org.

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* 1. Your (the person doing the nominating) Contact Information

Name

Email Address

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* 2. Nominee Contact Information

Name *

Employer *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number

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* 3. Nominee Race/Ethnicity

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

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* 4. Nominee Age Range

Under 20

20-30

31-40

41-50

51-60

Over 60

2017 Women's Champion Nomination Form

Deadline for Class of 2017: March 31st, 2017

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* 1. Your (the person doing the nominating) Contact Information

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* 2. Nominee Contact Information

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* 3. Nominee Race/Ethnicity

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* 4. Nominee Age Range

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* 5. How has this person been affected by Alzheimer's disease?

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* 6. Is or has the nominee been involved with the Alzheimer's Association?

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* 7. Why do you feel this person would make a great Class of 2017 Women's Champion?

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* 8. Is there anything else you want us to know about this nominee?