Lifesaving Award Nomination V2 NominatorPlease enter your information as the nominator for this Lifesaving Award.Your Name(Required) First Last Your Employer(Required)Your Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Email(Required) Your Phone(Required)Incident DescriptionPlease provide the following information (refer to Guidelines 3-7).Incident Date(Required) MM slash DD slash YYYY Approximate Time of Incident(Required) Hours : Minutes AM PM AM/PM Victim(s)Click the + to add additional namesFirst NameLast NameDid they survive? (Yes/No) Add RemoveLocation of Incident(Required) City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Describe the lifesaving incident(Required)Include, in detail, what HANDS ON assistance/aid was provided to the victim by the nominee(s), to treat injuries sustained. For multiple nominees, describe what each person did. Include the outcome of the rescue efforts.Nominee InformationLifesaving NomineeEnter each individual nominee covered by this submission Name Actions Edit Delete There are no Nominees. Add Nominee Maximum number of nominees reached. Photo ReleaseFor print and promotional materials that include a nominee photo, nominees must complete and sign a photo release. Photo releases and photos must be received by the deadline stated in the guidelines. You may submit signed and scanned releases and upload photos with this submission, or the nominees may submit their release later.Upload signed Photo Release form for each nominee Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 4 MB. Nominee PhotosFor a group of nominees, either individual photos or a group photo is acceptable. Upload Individual Nominee Photo(s)Minimum 450px wide by 600 px high. Drop files here or Select files Accepted file types: jpg, jpeg, png, Max. file size: 12 MB. Upload Group Photo of NomineesMinimum 1300 px wide by 600 px high. Drop files here or Select files Accepted file types: jpg, jpeg, png, Max. file size: 12 MB. Additional Statements / Supporting EvidenceUpload additional supporting documentationAllowed file types: pdf | doc | docx | txt Drop files here or Select files Accepted file types: pdf, doc, txt, docx, Max. file size: 3 MB. Provide any other information that you feel would assist the Advisory Board in their evaluation.EmailThis field is for validation purposes and should be left unchanged.
