2019 Pediatric Champion of the Year Award Nomination Form

Wednesday, May 22, 2019 is National EMS for Children Day.

In honor of this special day, the EMS for Children of Wisconsin is now accepting nominations for the 2019 Pediatric Champion of the Year Award.

This award is granted to an EMS crew or station that has displayed outstanding care for a child in a medical emergency or trauma event, demonstrated exceptional effort in influencing the development of pediatric training or quality improvement programs, or worked toward creating injury prevention efforts.

To submit an application for the Pediatric Champion of the Year Award please complete the below form by April 1, 2019. To be eligible, the event or program must have occurred in the 2018 calendar year. 

Contact Erica Kane at ekane@chw.org or 414-337-4572 with questions. 

Question Title

* 1. EMS agency name:

Question Title

* 2. Names and titles of crew members nominated:

Question Title

* 3. What is the date that the event or program occurred/started? Program or event must have occurred in the 2018 calendar year to be eligible.

Date 

Question Title

* 4. Please provide a brief description of the event or program and why you feel this crew deserves a special honor and recognition. Please limit to 500 words or less.

Question Title

* 5. Please provide your contact information.

Question Title

* 6. Do you have any other comments, questions, or concerns?

T