MHA Ludwig Award registration Form

MHA Ludwig Award Registration Form

Name Of Nominated MHA Member Organization:
Name Of Program:
Name Of Key Contact Person For Program:
Title:
Address:
Address (cont.)
City:
State:
ZIP:
Phone:
Fax:	By providing your fax number, you agree to receive facsimile advertisements from the MHA.
Email:	*Required

Name Of Individual Submitting Nomination:
Organization:
Title:
Address:
Address (cont.)
City:
State:
ZIP:
Phone:
Fax:	By providing your fax number, you agree to receive facsimile advertisements from the MHA.
Email:	*Required


Number Of People Served During Program Year:
Estimated Annual Cost of Conducting The Program: $

Narratives

Program Overview:

Statement Of Problem And Goal:

Leadership Role:

Strategic Platform Role:

Program Design And Outcomes:

Assessment:

Sustainability:

Instructions for submitting nomination materials are outlined in the "Entry Requirements" and "Nomination Deadline and Submission" sections of the brochure.
NOMINATIONS MUST BE RECEIVED BY THE MHA BY THE CLOSE OF BUSINESS ON THURSDAY, FEB. 9, 2012. Electronic submissions may be made by visiting www.mha.org, clicking on the "About Us" drop-down menu, and then choosing "MHA Awards." Printed nomination form, overview and narrative may be sent to:
Ludwig Community Benefit Award
c/o Paige Hathaway
Michigan Health & Hospital Association
6215 West St. Joseph Highway
Lansing, MI 48917
Fax: (517) 327-4506