2009 Ellen Dailey Award

Because Health Care is a Right, Not a Privilege

2009 Ellen Dailey Consumer Advocate Award
Nomination Form Due April 6, 2009

Please read the Call for Nominations prior to filling this nomination form. This form needs to be completely filled out so the committee will have all of the information it needs to select the recipient who best exemplifies the characteristics celebrated by this award.

Nominee's Name:
Nominee's Address:
City, State & Zip:
Nominee's Phone:
Other contact information or notes:
Is this person or was this person a consumer of services at a HCH project?	Yes No Don't Know
If yes, which one?
If chosen, will the nominee be able to attend the 2009 National Health Care for the Homeless Conference and Policy Symposium in Washington, DC June 24-27?	Yes No Don't Know
Describe in 100 words or more the qualities you feel makes this person deserving of the Ellen Dailey award:
Please list two references who can tell us about the nominee's work in the community, including the person nominating the candidate:
Name: Check if nominator
Agency (if any):
Address:
City, State, Zip:
Telephone:
Name of second reference:
Agency (if any):
Address:
City, State, Zip:
Telephone:

Nominee's Name
Nominee's Address
Nominee's City, State and Zip
Nominee's Phone
Other contact information or notes:
Is this person or was this person a consumer of services at a HCH project?
If yes, which one?
If chosen, will the nominee be able to attend the 2008 National Health Care for the Homeless Conference and Policy Symposium in Phoenis, AZ June 11-14?
Describe in 100 words or more the qualities you feel makes this person deserving of the Ellen Dailey award:

Name
Agency (if any)
Address
City, State, Zip
Telephone
Name
Agency (if any)
Address
City, State, Zip
Telephone

2009 Ellen Dailey Consumer Advocate Award Nomination Form Due April 6, 2009

2009 Ellen Dailey Consumer Advocate Award
Nomination Form Due April 6, 2009