Illinois Capital Area Chapter
1045 Outer Park Dr.
Springfield, IL 62704
Phone: (217) 787-7602
Fax: (217) 787-7952
springfield@il-redcross.org
   
 
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Coles and Clark Counties
Central Prairie Chapter
 
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Hero Nomination Form

Nominator Information
Full Name:
Street Address:
City:
State:
Zip:
Country:
Home Phone:
Work Phone:
Cell Phone:
Date of Birth:
Email Address:
Are you willing to talk on camera about your nominee? Yes      No
Nominee(s) Information
Full Name:
Phone Number:
Email Address:
Street Address:
City:
State:
Zip:
Country:
If Applicable, please include any additional names of nominees with contact information:
Award category for which you are nominating this person or group:
What is your relationship to the Nominee?
In the space below, please describe the Heroic action/dead of your hero.
Who it impacted, how it fits into the hero category you're submitting for,
and why they deserve to win (in under 600 words please):

Witness of Act/Deed/Service
Witness 1:
Full Name:
Street Address:
Phone Number:
Email Address:
Witness 2:
Full Name:
Street Address:
Phone Number:
Email Address:
To submit links to supporting materials, you may paste them in to the box below.
If you have other files you would like to submit,
you may email them directly to wlind@il-redcross.org
 
 
Illinois Capital Area Chapter, 1045 Outer Park Dr., Springfield, IL 62704 / Phone: (217) 787-7602 / Fax: (217) 787-7952 / springfield@il-redcross.org

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