Safe Routes to School Programs

The Governor’s Council Conquering Obesity Award

Individual – Honors an individual who has conquered obesity through dedication to physical activity and healthy eating.

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 any obstacles the nominee has overcome in order to make physical activity and healthy eating a part of his/her regular routine. Please include background information that highlights the inspirational nature of this individual’s commitment. (5 points)

What was the catalyst for this individual to make a lifestyle change? (5 points)

Describe the lifestyle changes the individual has made. (5 points)

How has the individual inspired or influenced others to make positive lifestyle changes? (5 points)

Please list any other recognition or acknowledgement this person has received (newspaper stories, television interviews, awards, etc.). In addition to what you’ve already told us, please share any observations or factors that make this person an excellent choice for this honor. (5 points)