| Award Application: |
*Please check the award that this nomination is for: |
Lifetime Achievement Award
EMT of the Year
MICT of the Year
Donald E. White Educator of the Year
Administrator of the Year
Physician of the Year
EMS Support Person of the Year
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| Nominee Information: |
*Nominee's Name |
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Mailing Address
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City |
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State |
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Zip |
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*Phone # |
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Fax |
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*E-mail Address |
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*Level of EMS Certification |
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Service Affiliation or Employer |
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Primary Occupation |
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| Nominator Information: |
*Nominator Name |
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Mailing Address
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City |
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State |
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Zip |
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*Phone # |
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Fax |
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*E-mail Address |
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Relationship to Nominee |
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Does the nominee know this nomination has been submitted or would you prefer it to be kept confidential until winners are announced?
Knows
Please keep it confidential |
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If the person you have nominated is the winner of the KEMSA Award and is eligible for the corresponding NAEMT award, will you be available to assist in the NAEMT application process?
(This information will not be used in the award selection process.)
Yes, I can assist in completing the NAEMT award application.
I am not able to assist with the NAEMT application.
I am unsure of my availability at this time. |
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| Additional Information : |
*In 1,000 words or less, please indicate why you think this individual should receive this award, including information about how the nominee:
- provides superior patient care;
- is an effective advocate for patients and their families;
- works with peers to foster a positive work environment;
- demonstrates professionalism in interacting with patients, their families and other medical professionals; and
- demonstrates his/her commitment to continuing professional education.
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| Attach up to three (3) letters of support for the nominee. |
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Local media contacts to whom press releases should be sent:
(Please include company, reporter's name, and complete address or e-mail) |
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| Other information: |
- The same person or organization may nominate each individual or organization for only one award per year.
- Photocopies of any newspaper articles or other related items that support your nomination need to be submitted electronically (scan documents if needed) and submitted to Debbie Glenn, Awards Committee Chair. Audio and videotapes will not be considered.
- For the KEMSA Awards Committee Policy, click here.
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Nominations must be submitted by July 9, 2010
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