Mother of the Year Award Nomination Form

Nominator Name*

Nominator Email*

Nominator Phone*

Partner Organization

Name of Nominee*

Nominee Address*

Nominee Email*

Nominatee Phone*

Award Category (check one):

Judy Wilson-Griffin Maternal Health Equity ChampionDr. Corinne Walentik Provider/Practitioner ChampionDr. Terry Leet Researcher AwardAlderman Gregory Carter Community Champion

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

Why do you think this person deserves the award?

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