East Texas Medical Awards Nominations Form

ETMA Awards Nomination

Please fill out this form to nominate for an award. You may use this form to make more than one nomination.
1. Choose the Award
Choose the award You are nominating for:

Community Health Champion - Recognizes an individual who has made a significant impact on the health and well-being of the community. Nominees may be honored for leadership, advocacy, outreach, or innovative efforts that improve access to care, promote healthier lifestyles, or strengthen community health. Nominees may include administrators, nonprofit leaders, public health professionals, community advocates, educators, nutritionists, chiropractic care providers, dentists, optometrists, audiologists, and others working to improve community health.
2. Nominee Information

Nomination Statement: Please provide specific examples of the nominee’s impact, accomplishments, and contributions in patient care, leadership, or community health. Aim for 200–500 words. Judges will use this to evaluate the nomination.
Nominee's Name

First NameLast Name
Reason For Nomination
Nominee's Organization or Affiliation
Where do they work?
Nominee's Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Nominee's E-mail Address
Nominee's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Your Information
Your Name

First NameLast Name
Your E-mail
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ETMA Awards Nomination