Lifestyle Change Award

LIFESTYLE CHANGE AWARD

Nomination Form

The American Heart Association wants to recognize individuals who have made positive changes to improve their quality of life and health, and influenced those around them to do the same. No change is too small and every accomplishment is significant and should be celebrated!

Nominations can be submitted by friends, co-workers, relatives, or individually. Winners will be chosen by the Building with Heart Committee and announced at the Building with Heart celebration event on Thursday, May 16, 2019.

Deadline for nomination submission: Friday, April 26, 2019

Fields marked * require an entry.

Nominee Name:

Nominee's Company/Worksite?

Phone and Email of the nominee so we may contact them is he/she is selected?

In what way has this person improved his or her lifestyle?*

Please describe the person’s accomplishments in increasing physical activity.:*

Please describe the person’s accomplishments in establishing healthier eating habits/Weight Loss.:*

Please describe the person’s accomplishments in managing heart-related risk factors.:*

Please describe the person’s accomplishments in changing the lifestyle, not only of themselves, but of those around them.:*

Why do you think this person deserves a Lifestyle Change Award? Did he/she lose weight? Start exercising more? Improve his or her blood pressure? Change the health of others, including themselves? Please include information regarding his or her success.:*

Relationship to Nominee:

Contact Information

Company:

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country / Location:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Email:*