Award Nomination Form

Nominations must be submitted by April 28, 2017.

Nominator Name*

Nominator Email*

Nominator Phone*

Partner Organization

Name of Nominee*

Nominee Address*

Nominee Email*

Nominatee Phone*

Award Category*
Dr. Terry Leet Researcher AwardDr. Corrinne Walentik Provider/Practitioner ChampionAlderman Gregory Carter Community Champion

What contribution has your nominee made to maternal and child health?

Why do you think this person deserves the award?

How does your nominee create racial equity in maternal and infant health?

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