Nomination Form - Minnesota WIC Everyday Hero 2017

Nomination Form - Minnesota WIC Everyday Hero 2017

Instructions:

Information on the Everyday Hero award can be found at [insert URL]. To nominate someone for the Everyday Hero Award:

·  Complete this nomination form.

·  Local Agencies may submit up to two nominations.

·  Obtain at least two letters of support: one from the nominee’s agency WIC Coordinator, and the other from the nominee’s colleague(s) and/or public health partners.

·  Submit this form and letters by Friday, June 16th to your region’s WIC Advisory Group representative (see accompanying list).

Click and type in the shaded areas to complete the form.

Question? Contact your WIC Advisory Group representative.

Person Being Nominated:

NAME:
ORGANIZATION :
WIC POSITION:
TELEPHONE NUMBER (day):
E-MAIL:

Person Making the Nomination:

NAME:
ORGANIZATION :
POSITION:
TELEPHONE NUMBER (day):
E-MAIL:

Description/Contributions of the Nominee:

1.  Describe the nominee’s role in WIC.
2.  Summarize the nominee’s qualities making them an Everyday Hero. [Note: If WIC Coordinator is making the nomination, the WIC Coordinator letter of support may be used here]
▪ 

Local Agency WIC Coordinator Approval

______YES ______NO Signature______

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