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*

Nominee Phone*

Award 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.

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 April 28, 2017.

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