Nomination Form

'Of The Month' (OTM) Nomination Form

- Your Information

Date Submitted:____________________

Name:______________________________

E-mail:______________________________

Phone Number: ______________________

Affiliation (circle): RHA General Board RHA Executive Board RD RA Other

· - Organizer’s Information:

Name(s) of person(s) who planned and executed the program: ___________________________________

_________________________________________________________________

· - - Program Information:

Building:_______________ Date(s) of Program: _____________

Number of People in Attendance:____ Day of Program: S M T W TH F S

Time Spent to Organize:______ Cost of Program:_________________

Was a Guest Speaker or Presenter Invovled (circle): Yes No

Program Category (circle): Community Service Diversity Educational Social

Where the program idea came from:

_______________________________________________________________________________

Please give a detailed description of the program & who hosted it:

_______________________________________________________________________________

Goals of the Program:

_______________________________________________________________________________

The Possible Long-Term Effects of this Program:

_______________________________________________________________________________

Thank You for Your Participation

Feel Free to Email Your Submission to mvisaggio@gmail.com