2018 Nomination Application - OTPC Community Health Champion Award Program

COMMUNITY HEALTH CHAMPION AWARD

APPLICATION DEADLINE: July 1, 2018
All winners will be notified on or before July 6, 2018 and will be recognized at a special awards luncheon during the OTPC Annual Conference on August 30, 2018 at the Moore Norman Technology Center, South Penn Campus in Oklahoma City.

*Application cannot be saved while in progress*
I. Nominee Information

Please complete the below section with information for the organization, coalition or partnership being nominated for the Community Champion Award.
Organization/Coalition/Partnership Name*
Organization/Coalition/Partnership Contact Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Website
II. Additional Nominee Information
Nomination Categories*

TobaccoObesityChildren's HealthBehavioral HealthOther
Initiative/Project/Event Name*
Target Audience*
Key Partners Involved*
III. Essay Questions

Please note word limits for each question.
Describe how the nominated initiative, project or event has impacted the quality of life for the identified target audience.*

500 word limit0/500
What are the goals and objectives of the nominated partnership or coalition?*

500 word limit0/500
Explain how the initiative, project or event created systematic, policy or behavior change in your community.*

500 word limit0/500
Describe how this initiative, project or event will be sustained in your community.*

500 word limit0/500
Describe the specific contribution made by each partner involved with the initiative, project or event.*

750 word limit0/750
IV. Supplemental Documentation

All supplemental documentation must be submitted at the time of the application in order to be evaluated. The approved documentation may include photos, newspaper articles, event flyers, website links, social media pages, letters of support, etc. A MAXIMUM OF FIVE ITEMS MAY BE SUBMITTED PER APPLICATION.
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Website/Social Media
Website/Social Media
Website/Social Media
Website/Social Media
Website/Social Media
V. Nominator Information

Please complete the below section with information of the individual nominating the above organization, partnership or coalition.
Nominator Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Where the confirmation email will be sent.
VI. Nominator Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
E-Signature:*
Application Date*

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COMMUNITY HEALTH CHAMPION AWARD

I. Nominee Information

II. Additional Nominee Information

III. Essay Questions

IV. Supplemental Documentation

V. Nominator Information

VI. Nominator Signature