2024 Champion Nomination Form
My Mental Health Matters is an initiative that is dedicated to raising awareness about mental health issues and promoting a supportive community. This could not be done without the help of dedicated and committed Mental Health Professionals and Advocates who serve their communities. They continue to make a difference through education, service, and awareness. It's time to shine the spotlight on these individuals. *Please select the award below to nominate your 2024 My Mental Health Matters Champion and fill out the form completely for your submission to be counted.
1. Choose the Award
Choose the Award
*
Youth Mental Health Champion
Young Adult Mental Health Champion
Adult Mental Health Champion
Caregiver Mental Health Champion
Organization Mental Health Champion
Clinical Mental Health Champion
Mental Health Coach/ Champion
Mental Health Advocate Champion
A System of Care Mental Health Champion
Instructor or Teacher Mental Health Champion
Reason For Nomination - Nominee's Notable Activities and Accomplishments
*
Use this space to explain why you or your nominee deserves the selected award. Describe the Nominee's notable activities and accomplishments-personal, professional,, or otherwise.
Reason For Nomination - Nominee's Impact in the Community
*
Use this space to explain why you or your nominee deserves the selected award. Describe how the Nominee is/has been instrumental in initiating or leading efforts to benefit our community.
Any other information you would like to include about the Nominee:
*
Use this space to explain why you or your nominee deserves the selected award.
2. Nominee Information
Nominee's Name
*
First Name
Last Name
Nominee's Phone Number
*
-
Area Code
Phone Number
Nominee's E-mail Address
*
Confirmation Email
3. Your Information
Your Name
*
First Name
Last Name
Your E-mail Address
*
Your Phone Number
*
-
Area Code
Phone Number
Please upload a Photo of the nominiee
Browse Files
Drag and drop files here
Choose a file
Cancel
of
By signing below, I give LWSC Community Circle and My Mental Health Campain the rights to use any portion of, or all of my writings, photographs, images, painting, videos, artwork, and/or drawings (hereafter referred to as "submissions(s) for their newsletter and any promotional use. I also acknowledge that all images provided by me for use by LWSC Community Circle and My Mental Health Campaign has been approved and released from any copyright(s) infringement. LWSC Community Circle and My Mental Health Campaign, nor any of its affiliated companies, board members, or employees, can be held liable for any content submitted within the content.
*
Send Nomination
Send Nomination
Should be Empty: