Lifestyle Change Award Nomination Form

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LIFESTYLE CHANGE AWARD

Sponsored Locally By:

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Lifestyle Change Award Nomination Form

Submission Deadline: April 15, 2013
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; every accomplishment is significant and should be celebrated! Nominations can be submitted by friends, co-workers, relatives, or individually. The Top 3 Finalists will be chosen by a selection committee and the winner will be determined by walk participants who vote at the Greater Portland Heart & Stroke Walk on Saturday, May 18, 2013. (http://www.PDXHeartWalk.org)
Nominee name:
Company/Worksite:
How may we contact the nominee if he/she is selected?
Nominee phone:
Nominee email:
Nominated by:
Your phone:
Your email:
Your relationship to nominee:

In what way has this person improved his or her lifestyle? Please describe the person's accomplishments in the applicable areas below.
Increased physical activity:
Healthier eating habits/Weight loss:
Managing heart-related risk factors:
Changing the lifestyle, not only of themselves, but of those around them:
Insert Personal Story
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.
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The Lifestyle Change Award is sponsored locally by the Northwest Regional Heart Center at Adventist Medical Center.
Adventist Health encourages living well by promoting a healthy lifestyle - delivering whole-person care that nurtures body, mind and spirit. For more information about Adventist Health, please visit their website at www.adventisthealthnw.com.

Lifestyle Change Award Nomination Form

Insert Personal Story