HCHB Customer Awards: Community Impact Nomination Form

HCHB Customer Awards:

Community Impact Nomination Form

The Community Impact award honors organizations who are making a significant difference in their community, improving lives through extraordinary actions, efforts and programs. We look forward to learning more about your nomination.

Learn more about our HCHB Customer Awards here.

*All nominees must be from an organization currently using HCHB.

Nominator Information

Nominator's Full Name*

First and Last Name

Nominator's Email Address*

Nominator's Agency Name*

Name of the agency you are employed at.

Nominee Information

Agency Name*

Name of organization you are nominating.

Reason for Nomination*

Describe your nomination's contributions in impacting on aging, social, or community needs through outreach and/or special programs.

Community Impact Outcomes*

Describe the outcomes achieved through your nomination's community focused efforts.

Community Impact with HCHB

If applicable, how was the HCHB application used in developing the organization's outreach or program.

Relevant Publicity and News Coverage

If applicable, provide hyperlinks to any relevant media coverage we should consider for your nomination.

Upload Supporting Documents

If applicable, upload any relevant material we should consider for your nomination.

Drag and drop files here or

Release of Information

Opt In for Permission*

I release and grant Homecare Homebase authorization to reproduce, copyright, exhibit, broadcast, electronic storage and/or distribution of said text/photographs/film/video tapes/electronic representations, and/or sound recordings without limitation at the discretion of Homecare Homebase.

Company Description/Boilerplate

Short description of nominated organization.

Company Website Link*

Include the link to your company's website.

Send me a copy of my responses

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