NOMINATION FOR LIFESTYLE CHANGE AWARD
Sponsored By:
The American Heart Association wants to recognize individuals who have made positive
changes to improve their quality of life and health. No change is too small, and every
accomplishment is significant!
Nominations for the Lifestyle Change Award can be submitted by friends, co-workers or
relatives and individuals can nominate themselves. The winner will be chosen by a
volunteer committee.
Deadline for the nomination submission is October 14, 2016
Nominations can be submitted by:
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Emailing the completed form to [email protected]
Faxing the completed form to the attention of the Bakersfield Lifestyle Change Award at (559) 435-5286
Mailing the completed form to ATTN: Bakersfield Lifestyle Change Award
American Heart Association
Attn: Lifestyle Change Award/Bakersfield
14600 Yellow Lupine Dr.
Bakersfield, CA 93314
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Nominee Name: _______________________________________________________________________
Company/Worksite: ____________________________________________________________________
How may we contact the nominee if he or she is selected?
Phone: _______________________________________ Email: _________________________________
Nominated by: ________________________________________________________________________
Phone: _______________________________________ Email: _________________________________
Relationship to Nominee: ________________________________________________________________
In what way has this person improved his or her Heart Health?
Personal Story – Why do you think this person deserves a Lifestyle Change Award? Please attach information regarding
his or her success:
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Did he or she lose weight?
Start exercising more?
Improve his or her blood pressure or cholesterol?
Quit smoking?
This award is based on the timeframe between October 2015 – September 2016.