Submit your Healthcare Heroes Nomination


The nomination form below requires you to upload four (4) documents. Please be sure you have these items ready, as you will not be able to complete the process without them. They include:

1. A detailed one page summary that describes your nominee’s achievement.
2. The Nominee’s professional or related resume/CV
3. A fully completed and signed legal Certification and Release of Liability Form in which the nominator gives permission to NLM to participate in the Healthcare Heroes Awards program
4. A high resolution photo of the nominee (minimum size 5×7, 300 dpi; max. 10MB)

We also suggest you review the other required fields before beginning this process, so you are sure to know all the information you need to provide.

Please submit this form by Sunday, September 22, 2019. Thank you in advance for submitting a nomination to our Healthcare Heroes Awards.

  • NOMINEE'S INFORMATION

  • If you are providing an international address and a particular field is not applicable, please insert N/A in that field.
  • If you are providing an international address and a particular field is not applicable, please insert N/A in that field.
  • NOMINATOR'S INFORMATION

  • DETAILS OF YOUR NOMINATION

  • FILES TO BE UPLOADED

  • Accepted file types: doc, docx, pdf.
    In a detailed one-page summary, describe this professional's achievements based on the category you checked above. Please be as specific as possible regarding the research, patient treatment, and/or impact this individual has made in the healthcare industry, and how that person reflects the qualities of integrity, empathy, curiosity, creativity, passion, perseverance, innovation, and courage.
  • Accepted file types: jpg, pdf.
    You'll find a pdf of this form here, if you haven't yet downloaded it. Please print and sign this document. Then, upload your signed document in this section.
  • Accepted file types: doc, docx, pdf.
  • Accepted file types: jpg, png, pdf.
  • Accepted file types: jpg, pdf.
    You may wish to include newspaper articles, letters of commendation, articles published by nominee, etc.
  • CERTIFICATION

  • COMPLETE YOUR NOMINATION

  • Please submit this form by September 22, 2019. Questions? Contact our Healthcare Heroes Awards staff at healthcareheroes@libertymuseum.org

    When you hit submit, the nomination process is completed. Your form will be sent to the National Liberty Museum, and you will receive an email confirmation that it was received.

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