Twin Cities Lifestyle Change Award Nomination Form

Twin Cities LCA Form Header

Twin Cities Lifestyle Change Award

The Lifestyle Change Award recognizes individuals who have made a positive changes 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 Twin Cities Lifestyle Change Award can be submitted by friends, co-workers or relatives, or relatives, and individuals can nominate themselves.

Semi-finalists will be selected by a volunteer committee and a winner will be selected from among the semi-finalists in an online Facebook vote. We will notify the semi-finalists before the Facebook vote is launched. The final winner will be announced at the Twin Cities Heart Walk, May 4, 2013 at Target Field in Minneapolis.

The Twin Cities Lifestyle Change Award is sponsored by:

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Deadline for the nomination submission: March 15, 2013

* Denotes required field

*Nominee Name
Company/Worksite
*Phone
*E-mail Address
*Nominated By
Has the person you are nominating been informed of their nomination?	Yes No
*Phone
*E-mail Address
Relationship to nominee
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 and 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?