American Red Cross: Survey - 2014 Heroes Nomination Form

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American Red Cross Greater Chicago Region

2014 Heroes Nomination Form

	Nominator Information
*1.	Question - Required - Your First Name
*2.	Question - Required - Your Last Name
*3.	Question - Required - Your Phone Number:
4.	Question - Not Required - Alternate Phone Number
*5.	Question - Required - Your Preferred Email
*6.	Question - Required - Your Address (Number, Street, Unit):
*7.	Question - Required - Your City:
*8.	Question - Required - Your State:
*9.	Question - Required - Your Zip Code:
*10.	Question - Required - Are you available to attend the Heroes Breakfast in April 2014? Yes No
	The winners and their nominatiors will be interviewed for a video to be shown at the 2014 Heroes Breakfast. Filming will occur during business hours in March 2014.
*11.	Question - Required - Will you be available to participate in filming during business hours in March 2014? Yes No
	Nominee(s) Information
*12.	Question - Required - Will your nominee(s) be available to participate in filming? Yes No
*13.	Question - Required - Are your nominee(s) available to attend the Heroes Breakfast in April 2014? Yes No
	Please complete the information below about your hero(es). Please note: heroic acts must have taken place during the 2013 calendar year or represent multiple years of service.
*14.	Question - Required - Your Nominee's Name:
*15.	Question - Required - Nominee's Preferred Phone
16.	Question - Not Required - Alternate Phone Number
17.	Question - Not Required - Nominee's Email:
*18.	Question - Required - Nominee's Address (Number, Street, Unit) (Maximum response 255 chars, approx. 5 rows of text)
*19.	Question - Required - Nominee's City:
*20.	Question - Required - Nominee's State:
*21.	Question - Required - Nominee's County of Residence:
*22.	Question - Required - Nominee's Zipcode
*23.	Question - Required - Gender Female Male
*24.	Question - Required - Date of Birth (Month/Day/Year)
25.	Question - Not Required - Ethnicity
*26.	Question - Required - Occupation
27.	Question - Not Required - If applicable, please include the additional names of people you are nominating for this act. (First & Last Names) (Maximum response 255 chars, approx. 5 rows of text)
*28.	Question - Required - What is your relationship to the nominee(s)? (Maximum response 255 chars, approx. 5 rows of text)
*29.	Question - Required - Award Category - please select one Adult Good Samaritan Blood Services Citizenship Community Impact Disaster Relief Emergency Medical Assistance Firefighter Law Enforcement Military Nurse Youth Good Samaritan
	In the space below, please describe the heroic actions and/or deed of your nominee(s) in 300 words or less. Please answer the following questions in your essay...
*30.	Question - Required - 1. Heroic acts must have taken place during the 2013 calendar year or represent multiple years of service.List the date of the heroic action or answer "ongoing" if applicable:
*31.	Question - Required - 2. Where did the heroic act occur? (Please include the county where the heroic act occurred):
*32.	Question - Required - 3. What actions and/or deeds make your nominees(s) a hero?
*33.	Question - Required - 4. What impact has your nominee(s) made on your life, the life of the others, and/or the community?
*34.	Question - Required - 5. How would you describe the personal integrity of your nominee(s)?
*35.	Question - Required - 6. The mission of the Red Cross is to help others prevent, prepare for and respond to disaster. How does the nominee(s) live out the Red Cross mission?
	Please include contact information for at least one witness who can verify the heroic act and character of your nominee.
*36.	Question - Required - Witness 1, First & Last Name
*37.	Question - Required - Witness 1, Preferred Phone Number
38.	Question - Not Required - Witness 2, First & Last Name
39.	Question - Not Required - Witness 2, Preferred Phone Number
40.	Question - Not Required - How did you hear about the Heroes Breakfast? Community Newsletter or Posting Red Cross Board Member Heroes Breakfast Committee Member Red Cross Postcard Red Cross eBlast CBS2 The Tribune Tribune.com Other

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