Nominate a Community Champion

The third annual New York Community Champions Awards will be held on Thursday, November 7, 2019.

We are accepting nominations now through Friday, September 20, 2019.

Nomination Form

Please fill all the required fields (*) Please select captcha

indicates a required field.

Nominee Information:

*Name:

(*) Please Enter the value for Name.

*Title:

(*) Please Enter the value for Title

*Organization:

(*) Please Enter the value for Organization.

Work phone:

Please enter a 10 digit telephone number

Email:

Please enter a valid email address

Work address:

City:

State:

Zip:

Home address:

City:

State:

Zip:

* Home Phone:

(*) Please Enter the value for Home Phone Please enter a 10 digit telephone number

Cell phone:

Please enter a 10 digit Mobile number

*Personal Email:

(*) Please Enter the value for Personal Email Please enter a valid email address

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:

(*) Please Enter the value for Key Contribution

*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.:

(*) Please Enter the value for Nominee Activities

*What sets your nominee apart from other volunteers? (e.g. their positive attitude, they get their family and friends involved, etc.)

(*) Please Enter the value for Unique Qualities

*Please include any other contributions by which this individual helps improve the quality of life in the community:

(*) Please Enter the value for Additional Activities

*If you could describe this individual in one word, what would it be?

(*) Please Enter the value for Defining Word

Nominating Individual or Organization Information:

*Contact Name:

(*) Please Enter the value for Name

Nominating Organization:

Relationship to Nominee:

Organization Address:

City:

State:

Zip:

*Phone:

(*) Please Enter the value for Sponser Phone Please enter a 10 digit telephone number

Cell phone:

Please enter a 10 digit Mobile number

*Email:

(*) Please Enter the value for Email Please enter a valid email address

Organization Profile:

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

By submitting my information via this form, I consent to having Molina Healthcare collect my personal information. I understand and agree that my information will be used and shared in accordance with Molina Healthcare's Privacy Policy and Terms of Use.