Award Nomination Form

Nominations must be submitted by July 7, 2020.

Nominator Name*

Nominator Email*

Nominator Phone*

Partner Organization

Name of Nominee*

Nominee Address*

Nominee Email*

Nominee Phone*

Award Category*

Select one category.

Dr. Terry Leet Researcher Award

This category is for an individual, collaborative or institution making significant research contributions to maternal and child health.

Dr. Corrinne Walentik Provider/Practitioner Champion

This category is for an individual or institution that provides direct health or community services and uses their knowledge/practice to advocate for improvements in maternal and child health.

Alderman Gregory Carter Community Champion

This category is for a volunteer, consumer or front-line employee who exemplifies a commitment to the health of mothers and babies.

Judy Wilson-Griffin Maternal Health Equity Champion

This category is for an individual making a remarkable contribution to advancing racial equity in maternal health and demonstrates a commitment to bridging community and health care.

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

Why do you think this person deserves the award?

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

Nominations must be submitted by July 7, 2020.

PRINTABLE NOMINATION FORM

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