Please complete ALL areas of the form and submit by June 22, 2018.

Your Name:

Facility You Are Associated With:

Your Email:

Your Phone Number:

Person You Are Nominating:

Facility Nominee Is Associated With:

Select Award Category:
TrusteeMedia PersonalityState LegislatorState OfficialHealth Care ProfessionalHealth Care HeroYoung Professional (under 40)Post-Acute Care Champion

In 500 words or less, describe current or recent circumstances where this individual has gone above and beyond in making a contribution to or demonstrating a high level of commitment towards advancing a healthy community or the mission of their facility. Note: "Community" means locally (within their facility or community), regionally or on a statewide-level.

In 500 words or less, describe how this individual demonstrates leadership and passion in the advancement or promotion of quality health care in their community or in the state.

In 500 words or less, describe evidence of this individual's heightened involvement in addressing health care needs within their community/facility (or statewide, if applicable).

Testimonial Letters (Optional): To submit a testimonial letter or letters, please email to info@sdaho.org. Please include the nominee's name in the file name. For example: JaneDoe_YoungProfessional.doc.

Will you be submitting any testimonial letters?
YesNo