Person of Influence Award Submission

Person of Influence Award Submission
Nominee Name

First NameLast Name
Nominee's Place of Work
Nominee's Work Address

Street Address

Street Address Line 2

CityState

Zip Code
Please describe, in as much detail as you can, how this individual has impacted the CHD community in Kentucky and how it made you feel.
Please share why you are nominating this person for this award.
Please tell us about yourself. I am (please check one):

PatientFamily MemberHealthcare ProfessionalVolunteerSupporter
If your nominee wins the award, are you willing to record a brief video or audio recording about why you nominated them and what their contributions have meant to you?
Submitter Name

First NameLast Name
Submitter Phone Number
Please enter a valid phone number.
Submitter Email
example@example.com
All nominations must be submitted by midnight on September 30, 2023 to be considered for as a nominee. Each nominee is required to serve the Kentucky CHD community.

By selecting "Yes" and submitting this online form, you agree to Kerrington's Heart Inc and/or its partners collecting and storing the information you submit, including your personal contact information, in accordance with Kerrington's Heart Privacy Policy and applicable law. Kerrington's Heart or the organization where the medical professional works may contact you with questions about your submission.
If you agree check 'yes'.

Yes
Should be Empty: