Nominate a Good Samaritan

When you respond to a medical emergency and provide life-sustaining care, we are all inspired to greater acts of human kindness.

To nominate someone you know who should be considered for this award, please submit the following information:

Nominee Information

Nominee's First Name *

Nominee's Last Name *

Instructor's Full Name

Registry Number of Instructor

Date Nominee was trained/certified:

Type of Class Taken *

Nominator Information

Nominator's Full Name *

Company *

Email (we will keep it completely private) *

Mailing Address for Award (to Nominator) *

City *

State *

Zip *

Phone *

Fax

Description of Event / Crisis

Date of Incident *

Location of Incident

Please describe the situation and actions taken by the Nominee in as much detail as known: *

Local Media Information

Name and Phone # of local TV station

Name and Phone # of local Newspaper

Upload photo of Nominee if available

By submitting this nomination, I confirm that this information is true and accurate to the best of my knowledge.