Real Women Real Change Award Form

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The Real Women. Real Change. Award recognizes women 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 CLOSED as of Nov. 30, 2013.

Ten (10) nominees will be selected in December to represent the American Heart Association and UnitedHealthcare at Go Red For Women events in 2014. 8 finalists will be determined by a volunteer committee, 2 finalists will be determined by online voting.

If you experience difficulties with this online form, please download the Go Red Nomination form, complete and send to Julie Petr.

Real Women. Real Change. Award is presented by UnitedHealthcare Logo
 

  • Nominee:

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  • Nominated by:

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  • How has this person improved his/her lifestyle? Please describe the person’s accomplishments in the applicable areas below: 

  • I, the undersigned, agree to be a volunteer spokesperson on behalf of the American Heart Association (AHA) for its Real Women. Real Change Award to further its mission of fighting heart disease and stroke. I will share my health story with the AHA, the public and parties working with the AHA in support of its mission. I understand and agree that the AHA may share my health story, my name, address, phone number and other contact information with various media outlets including newspapers, television, radio, and magazines and with other third parties working with the AHA to provide educational information on heart disease and stroke to the general public.

    I further understand and agree that:

    1.                  The AHA may copy and distribute my health story and my likeness; and may create, copy, and distribute derivative works based upon my health story and my likeness in the form of print, videotape, film, slides, photographs, audio tapes, web site, internet, electronic media or other media.  The AHA shall own the copyright in any such derivative works and may license or convey the copyrights to third parties at its discretion.

    2.                  The AHA may disclose my health story to media representatives, including public relations agencies and others, for consideration for use in the AHA’s public relations and educational promotions and materials;

    3.                  The AHA may introduce me to media representatives but the AHA has no obligation to do so;

    4.                  I may be photographed and I will give interviews on my health story for use and publication in newspapers, magazines, television, radio or other media or with other third parties working with the AHA and will do so upon request of the AHA;

    5.                  I will receive no compensation from the AHA for the disclosure or publication of my health story;

    6.                  I may withdraw my consent to serve as a spokesperson before I have actually granted an interview to the media.

    7.                  Once the AHA has introduced me to the media representatives for the possible use of my health story, the AHA will have no further involvement in the writing, development or production of my health story; and

    8.                  The media outlet publishing my health story will own the copyright to the story and materials it publishes about me or that include references to or photographs of me. 

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