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KEMSA Annual Award Nomination Form
Organizational Achievement Awards

Nominations must be submitted by July 6, 2012

Award Application:
*Please check the award that this nomination is for:	Community Service Award BLS Emergency Medical Service of the Year ALS Emergency Medical Service of the Year
Nominated Organization Information:
*Organization
Organization Contact
Mailing Address
City
State
Zip
*Phone #
Fax
E-mail Address

Nominator Information:
*Nominator Name
Mailing Address
City
State
Zip
*Phone #
Fax
*E-mail Address
Relationship to Nominee
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

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.

Additional Information :
*In 1,000 words or less, please indicate why you think this organization should receive this award and how the organization has shown dedication, teamwork, and commitment to EMS. Achievement areas you can write about include: Innovations in prehospital care EMS system/program upgrades EMS-related certification of personnel Worker safety and well-being programs Innovations in EMS education and training Medical community involvement Injury- and illness-prevention projects Public-education projects

You may attach up to three (3) letters of support for the organization.



Local media contacts to whom press releases should be sent: (Please include company, reporter's name, and complete address or e-mail)



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 Mary Napier, KEMSA COO. Audio and videotapes will not be considered. For the KEMSA Awards Committee Policy, click here.
*Nominations must be submitted by July 6, 2012*

*required fields

(print a copy for your records then submit below)