ALL SUBMISSIONS DUE BY JUNE 25, 2018 by 11:59 p.m., Eastern Time.

Do you know a local Champion that is making a difference in the lives of older Americans in Central New York? Enter the WellCare® Champions Competition for a chance to be honored with a once-in-a lifetime, magical moment during a Syracuse Chiefs home game. For more details and the WellCare® Champions Competition Official Rules, visit www.WellCareChampionsNY.com.
 
Before completing your submission, review our Tips for Nominations here.

1. In your own words, why does your nominee deserve recognition?

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* 1. 1. In your own words, why does your nominee deserve recognition?

2. How have your nominee’s efforts made a difference for the better in the life of older Americans in Central New York? (Efforts can include, but are not limited to: creating solutions for relevant issues; enhancing the health and welfare of people with Medicare; advancing the cause for social justice; and/or collaborating to make Central New York a better place for aging adults.)

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* 2. 2. How have your nominee’s efforts made a difference for the better in the life of older Americans in Central New York? (Efforts can include, but are not limited to: creating solutions for relevant issues; enhancing the health and welfare of people with Medicare; advancing the cause for social justice; and/or collaborating to make Central New York a better place for aging adults.)

3. Is there a specific incident or turning point that motivated your nominee to take action? Please give example(s).

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* 3. 3. Is there a specific incident or turning point that motivated your nominee to take action? Please give example(s).

4. Does the nominee have a background or story that is so central to their identity that you believe their application would be incomplete without it? Please explain.

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* 4. 4. Does the nominee have a background or story that is so central to their identity that you believe their application would be incomplete without it? Please explain.

5. The WellCare® Grand Champion gets to designate a charity to receive a $10,000 donation from WellCare®. If your nominee was chosen as the WellCare® Grand Champion, what charity does he or she designate and why?

(Please note: The designated Charity must be a 501(c)3 tax exempt organization whose mission is to serve older adults or has programs or initiatives that are making a difference in the lives of an aging population. Examples of such charities, include, but are not limited to, Sheltering Arms Foundation, Meals on Wheels, Neighborhood Centers, Inc., Gateway to Care, and many religious organizations).

Name of Designated Charitable Organization

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* 5. Name of Designated Charitable Organization

Charitable Organization’s 501(c)3 Identification Number

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* 6. Charitable Organization’s 501(c)3 Identification Number

Website Address for Charity

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* 7. Website Address for Charity

Reason for Selecting this Organization (please provide details).

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* 8. Reason for Selecting this Organization (please provide details).

Nominee's First Name

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* 9. Nominee's First Name

Nominee's Last Name

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* 10. Nominee's Last Name

Nominee's Email Address

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* 11. Nominee's Email Address

Nominee's Phone Number

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* 12. Nominee's Phone Number

Nominee's Address (Street Address, City, State, Zip Code)

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* 13. Nominee's Address (Street Address, City, State, Zip Code)

By completing this form, I, (name of nominator) agree that I have reviewed the WellCare® Champions Official Rules located on the website at www.WellCareChampionsNY.com and that the nominee will be subject to such Official Rules.

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* 14. By completing this form, I, (name of nominator) agree that I have reviewed the WellCare® Champions Official Rules located on the website at www.WellCareChampionsNY.com and that the nominee will be subject to such Official Rules.

We like to recognize our nominators (if different than the nominee) – the person acknowledging what is special about your nominee. We also may need to contact you for further information.
Your First Name (Nominator)

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* 15. Your First Name (Nominator)

Your Last Name (Nominator)

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* 16. Your Last Name (Nominator)

Your Email Address

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* 17. Your Email Address

Your Phone Number

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* 18. Your Phone Number

Relationship to nominee (i.e. friend, co-worker)

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* 19. Relationship to nominee (i.e. friend, co-worker)

Have a question about the WellCare® Champions Competition or the nomination process, visit our website at www.WellCareChampionsNY.com or feel free to email us at WellCareChampions@WellCare.com.

WellCare® is a proud sponsor of the Syracuse Chiefs and the New York State Fair!

YY0067_LM_Chmpform_0317 IA 04/05/2017 updated 05/15/2018

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