KEMSA

Award Nomination Form - Cara Everhart Award

Nominations must be submitted by July 9, 2010

Nominated Individual(s)/Organization Information:
*Individual(s) or Organization
Mailing Address
City
State
Zip
*Phone #
Fax
E-mail Address

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

Additional Information :
*Please submit a one page summary statement describing how the nominee meets the award criteria and additional materials to support his or her nomination along with a current picture.
(You may attach up to three items.)



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



Other information:
Additional materials can to be sent electronically to Sarah House, EMSC Coordinator, or by mail to: Sarah House, EMSC Coordinator Emergency Medical Services for Children Kansas Department of Health and Environment 1000 SW Jackson, Suite 230 Topeka, Kansas 66612-1274
*Nominations must be submitted by July 9, 2010*

*required fields

(print a copy for your records then submit below)