Safe Routes to School Programs

Governor’s Council Champion for Health Award

Most communities have an individual or two who are always working to improve the health of its citizens. This could be someone who provides free bicycle helmets to neighborhood children; a community organizer who hosts a weekly farmer’s market; a parent who advocates for quality physical and health education in his/her child’s school; the leader of the local complete streets coalition. These are individuals who work on a grassroots level to make their communities healthier places to live for no other reason that it is the right thing to do.

Note: For the written portion of this nomination form (located at the bottom), it's recommended that you type your response in a separate word document first and copy/paste your response into the text box area. This will prevent the loss of data should you need more time to fill out this form.

Your Information *First Name: M.I.: *Last Name: *Phone Number: *Address: *City: *State: *Zip:

*Email: *Relationship to Nominee:
I'm nominating myself

Nominee's Information *First Name: M.I.: *Last Name: *Address: *City: *State: *Zip: *County: *Phone: *Email: *Age: Race: (Optional) Optional:

*Selection Criteria:

Each response limited to 500 words

Describe the work the nominated individual does to make his or her community a healthier place. Please include background information that highlights the inspirational nature of this individual’s commitment. (5 points)

What was the catalyst for this individual to take on this work? (3 points)

What has leading this grassroots effort meant to him/her (include a description of the internal and external rewards for the individual). (3 points)
How has leading this grassroots effort influenced or inspired others? (5 points)

How long has the nominee been a part of this effort? (2 points)

Describe the individual's time commitment around this effort. (2 points)