West Virginia Health Care Hero
Nomination Form

Celebrate a Health Care Hero in your community.

Use this form to nominate someone you know for induction into the Health Care Hero Hall of Fame. This honor is awarded to individuals who take personal initiative to improve access to and delivery of health services in West Virginia and in their local communities. This award is presented by West Virginians for Affordable Health Care.

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* 1. Your contact information

Name

City/Town

Email Address

Phone Number

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* 2. Contact information for the nominee:

Full Name

Occupation

Employer/Organization

City/Town

Email Address

Phone Number

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* 3. What is your relationship with the nominee? How long have you known them?

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* 4. Tell us why this person is a health care hero. Be specific! (You may also submit your story typed in an email or a Word document. Send entries to mariah@wvahc.org.

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* 5. If selected, your candidate may ask who nominated them. Is it ok to share your identity with them?

Yes, you may share my name.

No, please keep my name anonymous.

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* 6. Is it ok to contact you for more information if necessary?

Yes

West Virginia Health Care HeroNomination Form

Celebrate a Health Care Hero in your community.

Question Title

* 1. Your contact information

Question Title

* 2. Contact information for the nominee:

Question Title

* 3. What is your relationship with the nominee? How long have you known them?

Question Title

* 4. Tell us why this person is a health care hero. Be specific! (You may also submit your story typed in an email or a Word document. Send entries to mariah@wvahc.org.

Question Title

* 5. If selected, your candidate may ask who nominated them. Is it ok to share your identity with them?

Question Title

* 6. Is it ok to contact you for more information if necessary?

West Virginia Health Care Hero
Nomination Form