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John Pipe Awards Nomination Form

   

All submissions must include the following (unless optional noted):

  • This online nomination form completed and submitted.
  • One (1) or more supporting material(s) that illustrate achievements must be sent via email to ADAHighRiskPrograms@diabetes.org no later than May 31, 2013. (i.e., photos, newsletters, flyers, educational materials, letters, data, etc.)
  • Link to supporting video(s) uploaded to YouTube (optional)
  • Tribal Logo (optional)

Contact Denise Price-Brown at dcbrown@diabetes.org or Shondra McCage, Chair Awakening the Spirit Subcommittee at shondra.mccage@chickasaw.net if you have any questions.

Submission Deadline Date: Midnight, May 31, 2013

* = required field
 
*Diabetes Program Name
 
*Program Address
 
Website Address
 
*Program Contact Name
 
*Program Contact Title
 
*Program Contact Phone (and extension)
 
*Program Contact Email
 
*Program Description
  
  
  
  
  
 
*Award Category (may select more than one)
  
  
  
 
*Program Summary
 
DVD/Video YouTube link
 
*List Filename(s) of supporting documents
 
List Filename(s) of Program/Tribal Logo in jpeg format
 

Reminder: Please submit all files to ADAHighRiskPrograms@diabetes.org
 
   

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American Diabetes Association • 1701 North Beauregard Street • Alexandria, VA 22311 • 1-800-DIABETES (800-342-2383)

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