Guiding Star Awards - Children’s Health Foundation

Please fill out your information:


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Phone Number: Required
	Yes, I wish to receive periodic updates from Children's Health Foundation via email.

Please fill out the nominee information:

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Question - Required - Name and title of individual:

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Please indicate the applicable category:
Please make between 1 and 4 selections from the choices below.

	Children's Hospital Staff
	Children's Health Research Institute Staff
	Paediatric Physician at LHSC
	Thames Valley Children's Centre Staff

Question - Not Required - Nominee Email Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Nominee Telephone Number:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Nominee Mailing Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Children's Health Foundation reserves the right to use the nominee and nominator information in the context of the Guiding Star Awards. This may be through various communications materials, including interviews, video, photographs, and quotes in print media, on television, radio and social media unless otherwise requested.

The nominee has been informed of this nomination.

Please answer the following questions:

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Question - Required - 1. How long have you known the nominee and in what capacity?

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Question - Required - 2. Within which department/program and/or area of research does the nominee work?

3. How has this person contributed to each of the following core concepts of Patient, Client & Family Centred Care?

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Question - Required - Respect & Dignity:

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Question - Required - Information Sharing:

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Question - Required - Participation:

*

Question - Required - Collaboration:

After this nomination is submitted, you may submit up to 3 letters of support indicating why the nominee should be chosen. Instructions for submitting letters of support will be on the next page.

Guiding Star Awards Nomination Form

Please fill out the nominee information:

Please answer the following questions:

After this nomination is submitted, you may submit up to 3 letters of support indicating why the nominee should be chosen. Instructions for submitting letters of support will be on the next page.