Do you know a child who is a Safety Superhero? Tell us why and the child could be featured on social media and in our newsletter! (i.e. Does the child always remind the family to buckle up? Does the child wear a properly fitted helmet and encourage others to do the same? Does the child wear a U.S. Coast Guard-approved life jacket? Has your family created a fire escape plan and practiced it?).

Each Superhero will receive a "Certificate of Heroism” from the Safe Kids Missoula Coalition led by the Foundation for Community Health. If your child is chosen as the Safety Superhero of the Month, they will be awarded a gift bag full of goodies.

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* 1. Your Name 

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* 2. Please provide a valid email address where we contact you regarding this nomination.

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* 3. Child's Name

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* 4. Child's Age

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* 5. Please provide the Child's Mailing Address so we can mail the "Certificate of Heroism"

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* 6. Why is your/the child a Safety Superhero? Please be specific.

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* 7. Please insert a quote from your/the child about why they like being a Superhero!

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* 8. Please send a photo or video of your/the child performing super safety activities to foundation@fchwmt.org.

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* 9. By submitting this nomination form, I understand that my/the child’s name, photo and/or video may be used in marketing and promotions on platforms including E-News, Facebook, Instagram, printed materials and/or live presentations. In addition, I hereby grant and authorize Foundation for Community Health the right to copy, exhibit, publish, distribute and make use of any and all pictures or videos I submit with this nomination to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press releases, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization shall continue indefinitely, unless I otherwise revoke this authorization in writing. I waive the right to inspect or approve any finished product in which submitted materials appear, including written or electronic copy. I understand and agree that these materials shall become the property of Foundation for Community Health. I hereby hold harmless and release Foundation for Community Health from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate. *

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