Champions of Hope Nomination Form

September 19, 2012

Miami Valley Hospital is hosting the third annual Champions of Hope awards dinner for individuals in the Greater Dayton area who are making a difference in the fight against cancer. The event will recognize a Cancer Survivor, a Miami Valley Hospital Medical Professional, a Cancer Caregiver and a Special Person of Inspiration.

We are seeking nominations for four categories, and our guidelines for consideration are:

Cancer Survivor: An individual who has battled cancer, is noted for giving back to others, and has inspired hope and determination in others battling the disease.
Medical Professional: An individual from Miami Valley Hospital who has made contributions to the field over and above their professional responsibilities. A clinician who has touched the lives of one or more cancer patients.
Cancer Caregiver: An individual who has made a difference in the lives of patients with cancer through self-sacrifice and unwavering optimism.
Person of Inspiration: An individual, living or deceased, who has reached out or advocated for others in the fight against cancer in a meaningful, impactful way. A special person whose example truly inspires others to continue through their own struggles with cancer.

If you have questions or concerns, please call the MVH Foundation office at (937) 208-2700.

Please submit your nominations by June 15, 2012. Thank you!

I am nominating this candidate for: *

Survivor

Medical Professional

Caregiver

Person of Inspiration

Nominee's Name: *

Nominee's Address: *

Nominee's Telephone Number: *

Nominee's E-mail Address: *

Your Name: *

Your Address: *

Your Telephone Number: *

Your E-mail Address: *

As you write your nomination for a Champion of Hope, please reflect on the following questions and include this information:

Why are you nominating this person?: *

How long have you known her, or him?: *

How has this person made a difference, and what is their unique contribution to our cause? How have they made an impact?: *

Please tell us your candidate's story, explaining how he/she has contributed as a Champion of Hope in the fight against cancer.: *

What is their experience in the community in work against Cancer?: *

What else should we know about your candidate as a Champion of Hope?:

Please feel free to tell us any other stories, experiences, or observations you have about your candidate. We look forward to recognizing key individuals in our community. Thank you!

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