Annual Awards Nomination Application

Please use this nomination form to recognize individuals and organizations that have made a significant contribution to rural health.

Fill out a separate nomination form for each category or entry.

Please visit our website here for award criteria.

1 Nominee Information

2 Brief Summary

3 Your Information

Nomination Category
This nomination is for the following category: (Please select one)
- Senator McGee Award
- Dr. Gary Ogden Rural Health Practitioner of the Year
- Outstanding Rural Health Program
Nominee Information
Nominee Name:
Phone
Organization (If employed):
If nominee is an organization, list contact person and title
Contact Person:
Title:
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code
Rural area affected by project:
If nominating a collaboration, please name all partners and their roles:
References

Names and contact information for three references
Name:
Phone
Email
Name:
Phone
Email
Name:
Phone
Email

Brief Summary

Please provide a brief summary (500 words or less) of why you believe this individual, organization or program should be nominated.

15th Annual NYSARH Conference | September 22 & 23 |1000 Islands Harbor Hotel | Clayton NY

Nomination Category