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Nominate a Community Champion

For more information about Community Champions click here.

The 6th Annual Wisconsin Community Champions Awards Dinner in Milwaukee will be held on Thursday, October 12, 2017. We are accepting nominations now through August 4, 2017. For more information, contact the Community Engagement Team at WICommunityChampions@Molinahealthcare.com.

Nomination Form

* indicates a required field.

Nominee Information:

  • * Name:
  • * Title:
  • * Organization:
  • Work Phone:
  • Email:
  • Work Address:
  • City:
  • State:
  • Zip:
  • Home Address:
  • City:
  • State:
  • Zip:
  • * Home Phone:
  • Cell phone:
  •  
  • * Personal Email:

Nominee Profile:

Please describe the nominee’s community contributions, achievements and qualities that qualify him/her for consideration.
Please include specific examples in the following areas:
* What key contributions has the nominee provided to the community outside of his/her salaried job? Please be specific and include projects, events, donations, volunteer work, and any other service he/she provides to the community:
* What have been the results or influence of the nominee’s activities? Please include quantitative (e.g. how many hours in total this individual volunteered, how many organizations they volunteer with, how many individuals benefited from their efforts) and qualitative results.
* What sets your nominee apart from other volunteers? (e.g. their positive attitude, they get their family and friends involved, etc.)
* Please include any other contributions by which this individual helps improve the quality of life in the community:
* If you could describe this individual in one word, what would it be?

Nominating Individual or Organization Information:

  • * Contact Name:
  •  
  • Nominating Organization:
  • Relationship to Nominee:
  • Organization Address:
  • City:
  • State:
  • Zip:
  • * Phone:
  • Cell phone:
  •  
  • * Email:

Organization Profile:

Please describe the nominating organization’s mission and services (one paragraph).

 

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