nomination form


This is it—your chance to show us why your nominee should be the next Peoples Health Champion!

Make sure that you have all the information about your nominee prepared in advance so you can easily enter it into the form below. If you want to use any of our tips and suggestions on the “Inside Tips for Nominations” page to help determine what to write, reference them before you start completing the form.

Once you start completing the form below, you won’t be able to view the “Inside Tips for Nominations” page without losing any information you already typed into the form.

Once you complete the form, click the “Submit” button, and you’re done. We look forward to reading your nomination!

Please complete the form below. Mandatory fields are marked with an asterisk.*

  • 1. The Achievement

  • Describe a single, notable achievement that your nominee performed after the age of 65.

  • 2. Experiences (or events) that contributed to the achievement:

  • What in your nominee's lifetime do you think contributed to his or her ability to perform this achievement?

  • 3. Details about your nominee:

  • Please share any further details you may know about your nominee. The only required information is the nominee's first and last name, but every piece of information can help us in honoring each nominee.

  • Do you have documentation to support your nominee? If you would like to write a more descriptive nomination or have articles or other materials that you feel support the nominee, please attach them here. We accept PDFs, MS Word documents, and images. Maximum file size is 4MB.
    Drop files here or
    Accepted file types: jpg, pdf, doc, docx, tif, png, Max. file size: 4 MB, Max. files: 4.

    • 4. About You:

    • We also like to recognize our nominators, you — the people who acknowledge what is special about their nominees. We also may need to contact you for more information if you are close with your nominee and can provide us with additional details.

    • This field is for validation purposes and should be left unchanged.