A Celebration of Heroes
Nomination Form

(print this form, complete it and either fax or mail to contact information below)

I would like to nominate (person or persons) ______________________________________
Who lives at Street Address ___________________________________________________
City_______________________   St _____   Zip _________  Phone (_____) _____-______

If nominating more than one person for the same act, please complete this top portion only on a separate form for each person being nominated, then attach to this cover form.


For an act of:        _____ Lifesaving     _____ Courage         _____Leadership
                           _____ Inspiration    _____ Selflessness    


In the category of: _____  Community Impact          _____  Emergency Responder 
                           _____  Firefighter                     _____  Good Samaritan 
                           _____  Law Enforcement           _____   Medical 
                           _____  Military                        _____   9-1-1 Dispatch
                           _____  Workplace                    _____   Education

 
Date(s) the event took place: __________________________________________________

Specific place where it occurred:________________________________________________

Name and contact info of the person(s) who benefited: _____________________________

____________________________________________________________________________

Did the helper risk his/her life? __________________________________________________

How did it happen?  (Briefly tell what took place): __________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

The impact or result of his/her action was:________________________________________

____________________________________________________________________________

How do you know the Hero nominee?  ____________________________________________ 

Who else is familiar with what was done? (Names & contact info):_____________________

____________________________________________________________________________

Nomination submitted by:___________________________ Phone:(__)________________

Please attach any news articles, letters of commendation, etc.



Please send promptly to:
Hero Nomination, American Red Cross
352 Church Avenue, Roanoke, VA  24016
or fax to 540-985-3010

Send us an Email or Call 540-985-3539 for questions