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Individual Nomination Form * Indicates a required field


Five individuals will be selected for the award. To be considered for the award, the following requirements must be met.
A list of previous recipients can be found here.

For assistance with this form, please email connectionsjdg@healthcaregeorgia.org.

Five individuals will be selected for the award. To be considered for the award, the following requirements must be met.

Individual nominees must:

  • Be a volunteer or a previous volunteer for a health-related, nonprofit organization
  • Have made a passionate commitment to improving the quality of health in a Georgia community
  • Have unselfishly contributed their time to community activities
  • Serve as a role model and inspiration to others
Nominee Information


Alternate address

Nominator Information


Alternate address

Individual Award Criteria

Please email any attachments that you would like to include with your submission to connectionsjdg@healthcaregeorgia.org.


Once you press submit, this form cannot be revised. Upon submission, you will receive an email confirmation of your nomination.