Kalamazoo Lifestyle Change Award Nomination

Kalamazoo Lifestyle Change Award Nomination Form
The Lifestyle Change Award recognizes individuals who have made a positive change to improve their quality of life and health over the past year, such as losing weight, becoming active, eating healthier and/or managing chronic diseases such as diabetes and cholesterol.
Nominations for the Kalamazoo Lifestyle Change Award can be submitted by friends, co-workers or relatives, and individuals can nominate themselves.
The winner will be announced at the Kalamazoo Heart Walk on Saturday, April 27 ^th.
Deadline for the nomination submission: April 19, 2013
Nominee name:*
Company/Worksite:
Nominee phone:*
Nominee email:*
Nominated by:*
Your phone:
Your email:
Your relationship to nominee:
Has the person being nominated been informed of their nomination?
Yes No
In what way has this person improved his/her lifestyle? Please describe the person’s accomplishments in the applicable areas below:
Increased physical activity:
Healthier eating habits:
Weight Loss (please include any support systems such as gastric bypass surgery, medications, Jenny Craig, Weight Watchers, etc.):
Managing heart-related risk factors such as not smoking, diabetes, high blood pressure or high cholesterol. (Please include any medications, methods, etc.)
Other:
Personal Story
Other information we should know. For example, what obstacles did the nominee overcome to achieve his/her successful lifestyle change? Has he/she motivated others in his/her family or community to live healthier as well?
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Kalamazoo Lifestyle Change Award Nomination Form

Personal Story