Regional EMS Award for Outstanding Contribution to EMS for Children Nomination Form

CRITERIA: An individual or organization that demonstrates outstanding dedication and service to the contribution, development and/or enhancement of EMS for Children in Virginia.

ELIGIBILITY: An individual or organization with a significant contribution to the development or enhancement of EMS for Children in Virginia. Services cover a continuum of care, from injury prevention to prehospital care, emergency department and hospital services, and rehabilitation.

Select Award Category*

Award for Outstanding Contribution to EMS for Children

Select Regional EMS Council*

Nominee Name*

Nominee Address*

Nominee Email*

Work Phone

Cell Phone*

Agency Affiliation*

Nominee Certification Number

If nominating an agency, please include the agency license number here.

Position

Nomination Submitted By*

Address

Email*

Work Phone

Cell Phone*

DOCUMENTATION SUPPORTING NOMINATION

Read each statement below carefully and answer completely. Limit documentation to the information requested. Up to three documents may be attached to the nomination form. Of these items, one letter of support written by someone other than nominator must be included. Other documents may include a resume or CV, a newspaper article written about the nominee, etc.

Supporting Documentation

Drop files here or

Max. file size: 100 MB, Max. files: 3.

1. Brief Abstract of Person Being Nominated: Summarize and justify why this person should receive this award. You are encouraged to consider the following questions when providing your response to this section.*

a.) How does this individual or organization exemplify outstanding dedication and service delivery to EMS for Children? b.) Describe this individual or organization’s services, which cover a continuum of care from injury prevention to prehospital care, emergency department and hospital services and rehabilitation. c.) Do they participate in programs or committees for EMS for Children? d.) Have they been recognized for their programs or dedication to EMS for Children locally, regionally, statewide or nationally?

Photo Required: A photo of the nominee must be included. Try to send a color photo (with good lighting) with just the nominee in it. If it is an agency or organization, the photo can be a group shot of agency members, a picture of agency headquarters or a logo.*

Accepted file types: jpg, jpeg, png, gif.FileDescription

To verify the accuracy of the information provided in this nomination form, please type your First and Last Name, along with the date that you submitted this nomination form.

Name*

First Last

Date*

Regional EMS Award for Outstanding Contribution to EMS for Children NOMINATION FORM