SCEMSA Memorial - Honoree Nomination Form
Please fill in the information below the best you can. We can help gather information as needed. (Nomination Period those who passed away Jan. 1, 2025-Dec. 31, 2025.)
Honoree Name
*
First Name
Last Name
Agency where they worked or retired from:
Years of Service in EMS
Rank/EMS License (EMT, Paramedic, etc)
Date of Birth
*
Date of Death
*
Short Bio
Photo of Honoree
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Honoree's Family Contact Information (Please include a family member's name, phone number and/or email if you have it. If we can't contact their family, we can't invite them to the memorial.)
Your Name (as the nominator)
*
First Name
Last Name
Your Email
*
example@example.com
Your Phone Number
Please enter a valid phone number.
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