Twin Cities Start! Lifestyle Change Award Nomination Form

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, and individuals can nominate themselves. Winners will be chosen by a volunteer committee and honored at the Twin Cities Heart Walk, May 19, 2012 at Target Field in Minneapolis. The Lifestyle Change Award is sponsored by:

BCBS 2012 For the health of all

Deadline for the nomination submission: April 19, 2012

Nominee Name
Company/Worksite
Have you notified this person that you nominated them?
Phone
*E-mail Address
Nominated by
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
Managing heart--related risk factors such as high blood pressure and high cholesterol
Other
Personal Story – Why do you think this person deserves a Start! Lifestyle Change Award? Please include information regarding his or her success.