Ludwig Community Benefit Nomination Form

Nominee Information

Name of Nominated MHA-Member Organization

Name of Program

Name of Key Contact Person For Program

Title

Organization

Street Address

City

State

ZIP

Phone

Fax

Submitter Information

Name

Title

Organization

Address

City

State

ZIP

Phone

Fax

Email*

Approximate number of people served by program

Date of Program Operation

Estimated Annual Cost of Conducting The Program

Narratives

Program Overview

Statement Of Problem And Goal

Leadership Role

Mission and Vision Role

Program Design And Outcomes

Assessment

Sustainability

NOMINATIONS MUST BE RECEIVED BY THE MHA BY THE CLOSE OF BUSINESS FRIDAY, FEB. 15, 2019.
Any additional materials should be emailed to eleyko@mha.org.

What are the Michigan Health & Hospital Association’s initials (three letters)? *

Submit

* Required

Ludwig Community Benefit Nomination Form

Nominee Information

Submitter Information

Narratives

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