Lifestyle Change Award Nomination
Sponsored by: Molina Healthcare
Form
Your name
First Name
Last Name
Your email address
example@example.com
Your phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Nominee's name
First Name
Last Name
Is this a self nomination?
Yes
No
Does the nominee know they are being nominated?
Yes
No
Picture of nominee
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What type of lifestyle change has this person made?
Increased physical activity
Adopted healthier eating habits/weight loss plan
Stopped smoking or vaping
Managed blood pressure, cholesterol or blood sugar
Learned family's heart/brain history and risk factors
Other
Please describe why this person deserves recognition for their lifestyle change.
Submit
Should be Empty: