Regional EMS Award Nomination Form

Please complete this brief form to make your submission. Staff members will review the nomination and reach out to you for additional information. Supporting documentation, including a photo, will be requested, so please begin gathering this documentation.
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).

Describe 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:

Type the numbers displayed.(*)
Type the numbers displayed.
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