REGION:

PROGRAM TITLE:

PERSON(S) IN CHARGE OF PROGRAM:

ADDRESS:

PHONE:

EMAIL:

Target population (in numbers):

Number of people in attendance:

Number of people needed to organize:

On campus population:

Time needed to organize:

Date(s) of program :

Cost of program:

PLEASE GIVE A SHORT DESCRIPTION OF THE PROGRAM (NOT TO EXCEED 400 characters):

Origin of the program: (400 word maximum)

Goals of the program: (200 word maximum)

Positive and lasting effects of the program: (200 word maximum)

Short evaluation of the program: (200 word maximum)

How could this be adapted to other campuses? (200 word maximum)

Nominations must be typed in a readable font on this form in the space provided above and each area must not exceed 200 characters unless otherwise specified. Nominations not following this format may not be considered for a national award. No additional material will be considered. Nominations must be postmarked to the NRHH Regional Associate Director by the 15th of the following month of nomination.

REVISED MAY 1999