Are you (or do you know) someone age15-18 in the metro Chicago area involved in health advocacy, activism, prevention or education?We're looking for someone who is concerned about the current health care crisis, has great ideas about how to fix the health system, improve health in their community, or communicate in innovative ways about health issues and risks. Join the 2012 HMPRG Young Health Activist Challenge. Nominate someone you know, mentor, volunteer or work with or teach. Or feel free to nominate yourself. Submissions will be accepted from April 1 - -July 30. One winner will be selected and notified by September 15. The winner (along with his or her nominator and parents or guardians) will be invited to attend the HMPRG Awards Event on October 11, receive a CASH AWARD and appear in a brief video ( shown at the event, on our web and YouTube.) All young nominees will receive a mailed certificate of appreciation thanking them for their involvement in health activism; and will be invited to attend future HMPRG events.

Nominator Information

Date ______

Nominator Name & Title
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Organization______

Address ______

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City______State______Zip______

Nominator Email *______Nominator Phone Number______

Nominator Phone Number ______

Information about your nominee

Your Nominee's Name *______

I am nominating myself *Yes No

Age______

School or Organization *______Website______

How do you know the nominee *

volunteering school church work friend family member nominee is me Other

Nominator Essay: Explain in 250-600 words why your candidate deserves this award. You may email your essay along with this form , mail it to HMPRG, 29 E. Madison Suite 602, Chicago, IL 60602 or fax to Fax: (312) 372.2753. Make sure your name and email are included.

Nominee Essay: (Nominees who are notified about their nomination, and Self-Nominators)Please write a brief 250-600 word essay describing your work as a health activist. You may email your essay along with this form to , mail it to HMPRG, 29 E. Madison Suite 602, Chicago, IL 60602 or fax to Fax: (312) 372.2753. Make sure your name and email are included.OR if you prefer to shoot a (3 minute max.) Flip Camera or smart phone video about yourself send an email to the above address and we will send you instructions for uploading.

I am submitting an essay a video

Nominees, give us your Twitter best! Tell is in 140 characters why you are a health activist ______

Nominee's Address*______

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City______State______Zip______

Nominee's Email ______

Nominee's Phone Number______

Nominees please provide the name of a teacher or mentor who can give you a recommendation along with their contact information.

Mentor/Teacher______

Email______Phone______

Nominees under 18, please secure the signature of a parent or guardian before you send this form back.

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Name of Parent or guardian (if nominee is under 18) (Date)

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Signature of Parent or guardian (if nominee is under 18) (Date)

Good Luck!