Regional EMS Award Nomination Form

Please complete this brief form to submit your nomination. Staff members will review the nomination and contact you for additional information. Supporting documentation, including a photo and supporting documents/contact information, will be requested. Be sure to gather this information prior to submitting your nomination.
Regional EMS Award Selection(*)
Choose an option from the list above.

Name of Nominee/Agency/Program(*)
Please enter a valid nominee name.

Agency/Organization Affiliation(*)
Please enter a valid Agency/Organization name. Enter "None" if not affiliated with an organization.

Submitted By (name)(*)
Enter the submitter's name.

Submitter Email(*)
Please enter your email for follow-up from Council staff regarding this award nomination.

Submitter Phone(*)
Please enter a valid phone number using this format (123-456-7890).

Please write a paragraph describing why this person, agency, or organization is being nominated. Be as specific and thorough as possible.(*)
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Please refer to the EMS award criteria and ensure that your nomination addresses these criteria: https://www.vdh.virginia.gov/emergency-medical-services/governors-ems-awards-program/11-ems-award-categories-and-a-scholarship/

For nominations to be complete, supporting documents must be provided. You may either upload these documents using the link below OR provide contact information for individuals who can provide supporting information.
Supporting Documents
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Please upload any supporting documentation (letters of support, articles, resumes, etc.) that demonstrates why the nominee deserves this award here.

Please provide the name, title, email address, and phone number of individuals who may be able to provide a letter of support or other supporting documentation for the nominee. If you upload these documents directly, please type "files submitted" in this box.
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Please upload a picture of the individual being nominated or a picture/logo of the agency/organization being nominated.(*)
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Type the numbers displayed.(*)
Type the numbers displayed.
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