Recipient of
Real Heroes Breakfast Nomination Form
Central New York
Every now and then, an unselfish and extraordinary action on behalf of a
neighbor, a co-worker or even a stranger can change another person’s destiny
and, at the same time, our own. In that moment Ordinary People,
Become Real Heroes. Do you know a Real Hero?
Nominator Name:__________________________________________________
Address:____________________________________________________________________
Day Phone:_______________________Evening Phone:_____________________________
Business:___________________________________________________________________
Email Address:_______________________________________________________________
Hero Name:_______________________________________________________
Address:_____________________________________________________________________
Day Phone:________________________Evening Phone:______________________________
Occupation:___________________________________________________________________
Email Address:________________________________________________________________
Award Categories
Adult Good Samaritan (21 & over)
Animal Rescue
Blood Donor/Services
Education
Fire Rescue
Good Neighbor
Law Enforcement
Lifeline
Medical
Military
Workplace Safety
Youth Good Samaritan (20 & under)
Presented to an ordinary citizen who used life-saving skills to save the life of
another (age 21 & older)
Presented to the family of a pet who was instrumental in saving a life, or an
ordinary citizen who was instrumental in saving an animal’s life
Presented to an ordinary citizen who has helped save countless lives with blood
donations
Presented to an educator or layperson who used life-saving training to save the
life of another in an educational setting as school or college
Presented to a firefighter, volunteer or paid, whose life-saving actions
exemplifies the very highest standards of their calling
Presented to an ordinary citizen or professional rescuer involved in rescuing a
person from a life-threatening situation
Presented to a law enforcement officer whose life-saving action exemplifies
the very highest standards of their calling
Presented to an individual or a 9-1-1 dispatcher or caller who utilized
emergency communications to save the life of another.
Presented to a medical professional, an organization, or an ordinary citizen
whose life-saving action exemplifies the very highest standards of their calling
Presented to a member of the Armed Forces (active or retired, commissioned
or non-commissioned) whose life-saving actions exemplify the very highest
standards of their calling
Presented to a business owner, manager or employee whose preparedness or
life-saving action exemplifies the very highest standards of their calling
Presented to an ordinary citizen who used life-saving skills to save the life of
another (age 20 & under)
Nomination Statement:
Please select an award category on the previous page, and state why you are nominating this
candidate for a Real Heroes Award. Statements are limited to space on this sheet. Please Include any
supporting reports, news articles or names of witnesses we may call to verify the event. (A description
of each category is on the previous page). Return your nomination to the American Red Cross, c/o Real
Heroes Breakfast at 344 W. Genesee St. #100, Syracuse, NY 13202 or by Fax 315.234.2234 or by email
[email protected]. For questions, please contact us at 315.234.2225.
Type yYour story here….
If you know the name of the person(s) saved during this heroic act, please include their name
and contact information, if known, here:________________________________________________________________
Submission Deadline: August 19, 2016