GLMA Nursing Section Local Champion Award Nomination Form 2022

Nomination Form

Thank you for your nomination!

The GLMA Nursing Section Local Champion Award is given each year to an individual, group or institution working within or on behalf of the local LGBTQ community of the host city for the GLMA Annual Conference. GLMA's annual Nursing Summit will take place on Wednesday, October 19, 2022 in San Francisco. This year, we celebrate our 10th pre-conference Nursing Summit. We welcome any and all nominations.

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* 1. Your Name

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* 2. Your Phone Number

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* 3. Your Email Address

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* 4. Nominee's Name

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* 5. Nominee's Phone Number

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* 6. Nominee's Email Address

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* 7. Title (if any)

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* 8. Institution (if any)

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* 9. Degrees (if any and/or if known)

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* 10. Does the nominee know about their nomination?

Yes

Other (please specify)

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* 11. Area for which nominee is being nominated:

Practice

Education

Research

Policy

Activism

Other (please specify)

GLMA Nursing Section Local Champion Award Nomination Form 2022

Nomination Form

Question Title

* 1. Your Name

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* 2. Your Phone Number

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* 3. Your Email Address

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* 4. Nominee's Name

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* 5. Nominee's Phone Number

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* 6. Nominee's Email Address

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* 7. Title (if any)

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* 8. Institution (if any)

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* 9. Degrees (if any and/or if known)

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* 10. Does the nominee know about their nomination?

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* 11. Area for which nominee is being nominated:

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* 12. Please write a short paragraph explaining the contribution(s) of your nominee. (200 words)

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* 13. Are there any other comments you'd like to share about your nominee?