Name of Individual Organization being Nominated:

Address:

Phone Number:

Type of award to be nominated for (see below for description)
  Program Award is to be given for an innovative immunization program that help address areas of special
        concern and develop a broad based community program that promotes immunization.

  Volunteer Award is to be given to an individual who has shown great initiative and promotes active support
        for the development and administration needs of immunization programs.

  Policy Maker Award is given to an individual that has brought diverse groups together and has provided
        outstanding leadership and direction in support of immunization and family health issues.

  Other: (Please describe) 
 

Brief description of the nominee’s efforts to promote, support or provide leadership in immunization and child health issues in the community:
Type your desription here.

Your Name:

Your Phone Number: