Joan H. Tisch Community Health Prize Online Application

Information about the Nominator
Nominator's Name * First Last
Nominator's Title *
Nominator's Organization *
Nominator's Relationship to Nominee *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone (Work) * - ### - ### ####
Phone (Other) - ### - ### ####
Fax - ### - ### ####
Email *
Web Site
How did you hear about the prize?
(Please specify name of publication, website, media outlet, etc.) *
Information about the Nominee
Is the Nominee an Individual or an Organization? *
Individual Organization
Nominee's Name * First Last
Nominee's Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Nominee's Email *
Nominee's Phone (Work) * - ### - ### ####
Nominee's Phone (Other) - ### - ### ####
Web Site
First Reference
Name * First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone (Work) * - ### - ### ####
Phone (Other) - ### - ### ####
Fax - ### - ### ####
Email *
Attach Letter of Reference #1 (PDF) *

Attach Files

Separate signed letters of reference from two additional individuals knowledgeable about the nominee, and who can provide further validation of the nominee's reputation in the field and insight into the qualities and achievements that make the nominee worthy of The Joan H. Tisch Community Health Prize.
Second Reference
Name * First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone (Work) * - ### - ### ####
Phone (Other) - ### - ### ####
Fax - ### - ### ####
Email *
Attach Letter of Reference #2 (PDF) *

Attach Files

Separate signed letters of reference from two additional individuals knowledgeable about the nominee, and who can provide further validation of the nominee's reputation in the field and insight into the qualities and achievements that make the nominee worthy of The Joan H. Tisch Community Health Prize.
Written Narrative

A narrative written by the nominator describing the nominee's accomplishments, creativity, impact, and the specific public health initiative or program meriting this award.

Please include three separate sections in the narrative, with the headings of the three prize evaluation criteria:
1) Achievement
2) Imagination
3) Impact
In the Impact section, provide any specific outcome measures of program effectiveness and reach.

(Maximum 750 words)
Attach Written Narrative (PDF) *

Attach Files
Mailing List
Do you wish to be added to the Roosevelt House e-Mailing List to keep up to date on events and programs at the Roosevelt House Public Policy Institute at Hunter College? *
Yes No
Please make sure you have attached all of the required documents before clicking the submit button to submit your application.

Once your application has been submitted, you will receive an email confirmation within 24 hours.

Joan H. Tisch Community Health Prize Online Application

Joan H. Tisch Community Health Prize Online Application

Information about the Nominator

Information about the Nominee

First Reference

Second Reference

Written Narrative

Mailing List

Please make sure you have attached all of the required documents before clicking the submit button to submit your application.