EDAC Bill Chisolm Professional Service Award - Nomination Form

Sponsor Information

Name: *

Email Address: *

Address: *

Primary Phone: *

Work Fax: *

Nominee Information

Name of Nominee: *

Nominee Credentials: *

Nominee Email Address: *

Nominee Address: *

Nominee Primary Phone: *

Nominee Primary Occupation: *

Nominee Secondary Occupation:

Nominee Education

Please list the degrees the nominee has earned or is currently working toward. Please include the the school, city, state and the year for each degree listed.

Degree(s) Information:

Nominee Contributions to Athletic Training

Please include years of term when applicable.

Nominee is a member of (state associations):

Offices held in state association:

Committee involvement in state association:

Offices held within district:

Committee involvement within district:

Offices held at NATA:

Committee involvement at NATA:

Nominee Volunteer Contributions

Organization:

Duties:

Dates:

Additional Involvement (published research, public presentations, etc):

Please attach a description of the nominee’s involvement in the advancement of the provision of athletic health care services to ethnically diverse individuals or populations.

Description:

Please attach a description of the nominee’s contributions to the professional development and advancement of ethnically diverse athletic trainers and/or athletic training students.

Contributions to Professional Development:

Please attach letters of recommendation

Letter of Recommendation 1:

Letter of Recommendation 2: